OP Insights: Claim Status (Most Recent 90 Days)

Version 14.8

Overview

In this section you will find information on the Claim Status (most recent 90 days) section on the Overview tab in the Billing Center.

Billing Center: Overview Tab 

Why is this Section Important?

Claim Status metrics provide a good snapshot of the flow of claims from the practice to the clearing house and through to various insurance payers. Each practice needs to closely monitor this flow of information so that rejected claims can be corrected and resubmitted , allowing  all claims to be successfully adjudicated within the constraints of timely filing.

Current (not Daysheeted)

  • What is this?
  • A count of new claims that have not been included in a daysheet will be displayed.  
  • Keeping it Healthy:
  • The total number of claims should stay steady.  
  • It should not be more than one day’s worth of claims when following best practices for daily daysheets.
  • For security reasons, in order to avoid mistakes and to allow for reporting accuracy, daysheets should be run daily.
  • For More Information:
  • Double-click on the text.  OP will take you to the Claims + AR tab with current (not daysheeted) claims displayed.

Not Daysheeted Charges

  • What is it?
  • A total of all charges that have not been included in a daysheet will be displayed.
  • Keeping it Healthy:
  • The total number of charges should stay fairly steady.  
  • It should not be more than one day’s worth of charges when following best practices for daily daysheets.
  • For More Information:
  • Double-click on the text.  OP will take you to the Claims + AR tab with current (not daysheeted) claims displayed.

Not Daysheeted Payments

  • What is it?
  • A total of all payments that have not been included in a daysheet will be displayed.
  • Keeping it Healthy:
  • The total number of charges should stay fairly steady.  
  • It should not be more than one day’s worth of charges when following best practices for daily daysheets.
  • For More Information:
  • Double-click on the text.  OP will take you to the Claims + AR tab with current (not daysheeted) claims displayed.

Current, not Queued for Transmission 

  • Claim Status = Q0
  • What is this?
  • A count of new claims that have not yet been placed into the transmission queue or sent to the payer.
  • Keeping it Healthy
  • This number should hold one day’s worth of claims, and should return to 0 daily when the daysheet is processed.
  • If this number grows from one day to the next, investigate. Ensure that your practice workflow includes placing claims into the transmission queue and running a daysheet daily.
  • A large or growing number indicates a delay in your claims cycle.
  • For More Information:
  • To view the claims that have not yet been placed into the transmission queue, double-click on the text.  Office Practicum will take you to the Claims + AR tab with current, not queued claims displayed.

In Transmission Queue, not Sent

  • Claim Status = Q1
  • What is this?
  • A count of claims that are in the transmission queue will be displayed.
  • Keeping it Healthy:
  • This number should be remain small except during your close-out process of placing claims into the queue, running the daysheet and transmitting claims.  
  • If claims do not leave the queue, you will need to review the rejection queue.  A claim that gets “stuck” is most likely a rejection.
  • For More Information:
  • Double click on the text.  OP will take you to the transmission queue.

Sent, not Acknowledged

  • Claim Status = Q2
  • What is this?
  • A count of claims that have been sent to electronically where OP has not processed any reply from the clearinghouse or the payer.  
  • Keeping it Healthy:
  • To keep this information accurate, ensure that your billing workflow includes the processing of reports from your clearinghouse.  See the last metric in this section “Most recent acknowledgement date” to view the most recent report that has been processed.
  • This number should remain steady; if it grows from one day to the next, it is reason to investigate.
  • The date of submission should be recent (today or yesterday).  If time has passed from submission date, it is reason to investigate.
  • For More Information:
  • Double-click on the text.  OP will take you to the Claims + AR tab with sent, not acknowledged claims displayed.

Rejected or Denied, not Followed Up

  • Claim status = A3, A4, A6, A7, A8 or F2
  • What is this?
  • A count of claims that have been rejected or denied and follow up has not yet been performed.  
  • Keeping it Healthy
  • This should routinely be emptied after processing claim acknowledgements.
  • For More Information:
  • Double click on the text. OP will take you to the Claims + AR tab with the Rejected/Denied stage displayed.

Total Claims Acknowledged, Last 7 Days

  • What is this?
  • A count of claims that have been acknowledged by the clearinghouse over the last 7 days.
  • Keeping it Healthy
  • This number should remain stable with any shifts mirroring the business of your schedule.

Most Recent Acknowledgement Date

  • What is this?
  • This is the date that the most report from your clearinghouse was processed.
  • Keeping it Healthy
  • Clearinghouse reports should be processed daily.