IMPORTANT: Apex EDI does NOT reject or deny ANY Claims. All denials and rejections come directly from either the Payer's EDI department or the Payer's Clearinghouse. To better understand that process, click here.
There are many types of Statuses that can be associated with a Claim. This article will help to break down the main statuses that can be received by Apex from the insurance. The main Statuses are:
Before You Begin: You will first need to know how to search for a claim in this tab.
Sent to Payer
Sent to Payer means that Apex EDI has received your Claim and has electronically submitted it to the insurance company.
- If Sent to Payer is the active Status, this means that Apex has not received any status updates since you submitted the Claim.
- If a Claim has been in the Sent to Payer status for a long time and you haven't received any payment for the Claim, see Why Haven't I Received Payment on My Claim.
There are 2 Accepted Statuses you will see.
- Accepted "Payer (999)" - The first will most likely show first. This is an obligatory "message received" stating that the Claim was received and is in the initial stages of being processed.
- Accepted "Payer (277)" - Shortly after the first accepted message (mostly on the same day), your Claim will then receive a second status when accepted. This status means that the Claim passed all initial processing and has moved onto the payment, or adjudication, system.
NOTE: This does not guarantee your Claim will be paid; the Payer may still find an error with the claim and deny it for that reason. If you have a claim that is showing Accepted for a long time, and hasn't been paid yet, then click here.
This will be the most dramatic change made to the claims within the Apex system. You will notice that all claims that have been rejected will show both the status and the patient name in red. As with the other status types, you will need to click on the patient line to find a breakdown of the rejection.
When scrolling down, you will notice that the rejection message should be the most recent message received. This will show you what exactly was wrong with the claim and why it was rejected.
*If you receive a rejection message, and then an "Accepted Payer (277)" message afterwards, then that is an error from the payer. The claim is still rejected, the payer just sent the messages to Apex in the incorrect order.
Once you've gone over what the rejection is, you can then edit and resubmit the claim with any corrections needed. To learn how to resubmit a claim, click here. To see our list of common rejections, and how to correct them, click here.
When searching for these claims, you will see the status listed as either Paid, Complete, or Denied. Paid means that the payer paid on the claim and sent Apex EDI the EOB/ERA. Complete and Denied are essentially the same problem, something was wrong with the claim and the payer was unable to pay on it. We also receive EOBs/ERAs for these as well.
Normally an EOB/ERA would be found in the Electronic EOBs tab, and they would list all patients that were paid or denied on the same day. However, Apex EDI also receives individual EOBs for each patient, making things easier when looking for a singular patient's information.
To access this, you would search for the claim with the status you're wanting (in this example we will use the Paid status) and then click on the patient line.
Scroll down until you reach the final status of "Paid - Payer (835)".
On the right of the line you will notice that there are 2 options in blue; one will say Full EOB and the other will say Patient EOB. To view the individual EOB click on the Patient EOB option.
This will then pull up the patient's EOB for you to use as you need. If you need help with understanding why your claim denied, please click here.