Medical billing can be confusing - a claim lifecycle can take months to complete and isn't always straightforward. DocStation's goal is to make this process as transparent as possible, so you always know what's happening with your claims and what to expect next.

This article describes each status of the claim lifecycle to help you better understand your claims' history.

The claim status can be found next to the claim ID at the top of the claim tray, or in the Status column on the Claims Table.

The progress a claim has made through the lifecycle can be found toward the bottom of the claim tray in the History section.

A claim will typically flow automatically through each of the following statuses step-by-step until a determination is reached (e.g. Paid, Denied), though some status transitions are "forced". This means the claim was either manually transitioned to that status (by a user or by DocStation RCM) or that DocStation received clearinghouse or payer data for a status that was more than a single step ahead of the claim's current status and needed to be forced through the "skipped" step(s).

Draft

Definition: The claim has been created but has not yet been submitted.

Draft claims can be created by users or by DocStation Worker via Automation.

All data elements of a draft claim can be edited.

Invalid

Definition: The claim has either not passed a DocStation or clearinghouse validation or has not received a verified patient eligibility check and needs to be edited in order to move forward to claim submission. Check out this Help Center article to learn more about troubleshooting this status.

In Review

Definition: The claim has been submitted and requires review by DocStation Revenue Cycle Management (RCM) before it is released to the payer.

Processing

Definition: The claim has been submitted to the clearinghouse in preparation for submission to the payer.

The status transition from Processing to Submitted requires electronic confirmation from the payer that the claim was received. Not all payers provide this confirmation, so it is possible for a claim to remain in Processing status even though it has been submitted to the payer for adjudication.

Depending on a number of factors related to your account and the payer to whom the claim was submitted, claims may sit in Processing status for up to several weeks before moving to either Submitted status or one of the adjudicated statuses (Rejected, Denied, Paid).

Submitted (to Payer)

Definition: The claim has been submitted to the payer and is awaiting response from the payer regarding claim adjudication.

Depending on a number of factors related to your account and the payer to whom the claim was submitted, claims may sit in Submitted status for up to several weeks before moving to one of the adjudicated statuses (Rejected, Denied, Paid).

Rejected

Definition: The submitted claim failed to pass a clearinghouse-specific or payer-specific validation and was rejected. Rejected claims have not been adjudicated by the payer, and can be resubmitted after correcting the applicable field(s). Check out this Help Center article to learn more about troubleshooting this status.

For example, if a claim is rejected for "Incorrect Place of Service", click the Resubmit button to bring the claim back to Draft status, edit the place of service field in the Care Provided section, then submit the claim. The claim will flow through the lifecycle again from Processing.
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Denied

Definition: The submitted claim was successfully adjudicated by the payer and received a denied determination. Check out this Help Center article to learn more about troubleshooting this status.

In some cases, a denied claim can be resubmitted if an element of the claim was not correct. Click the Resubmit button to bring the claim back to Draft status, edit the applicable field(s), and submit the claim. The claim will flow through the lifecycle again from Processing.

Paid

Definition: The submitted claim was successfully adjudicated by the payer and received a paid determination. Note: claims can be paid a zero dollar amount. This is a proxy for a denied determination.

A paid claim can be reversed if it was incorrectly or inappropriately billed. Click the Reverse button to initiate this process.

Cancelled

Definition: The claim has been removed from the claim submission process. This cannot be undone.

A claim is typically cancelled very early in the lifecycle (usually from Draft or Invalid) usually because it was created in error and should never be billed.

Not Billable

Definition: The claim was not successfully adjudicated and should not be reprocessed. A manual status transition is required to move a claim to this status. This cannot be undone. Note: Not Billable status has been used as a representation of a finalized status for the purpose of removing these claims from any work queues for continued follow-up. This purpose will be replaced with a true Finalized indicator.

A claim is typically moved to Not Billable if the claim was Rejected and no further edits to any data element can be made before attempting resubmission.

Check out the Help Center collection for Medical Billing for more information. Still have questions? Ask DocStation in the chat!