There are times where Apex will send a claim to a payer, and it will say Accepted for long periods of time. During this time, some providers will try to access the claim on the payer portal, or contact the insurance customer support, and find no record of the claim. This is not due to Apex having issues with sending the claims, but more about the places that the claims are sent to. Apex EDI will send claims to one of two destinations:
- Payer Clearinghouse
- Payer EDI Department
When you see that the claim has been accepted on your Apex website, but the payer has no record of it when you contact them, that most likely means the claim is still with one of the two possible destinations.
There are clearinghouses, like Apex EDI, that are contracted specifically with an insurance company. These clearinghouses will go through all the incoming claims being sent to the insurance and perform all initial processing. If the claim passes their inspection, they will then forward the claim to the payer's EDI department.
It's important to note that the payer will have no access to the claim while it is with the clearinghouse. Should the claim reject at the clearinghouse level, then they should send it back to Apex EDI before forwarding to the insurance.
Payer EDI Department
When Apex has set up a direct link with the payer, this means we are bypassing a Payer Clearinghouse and submitting the claims directly to the payer's EDI department. This department will act the same as the clearinghouse, and process all incoming claims to either accept or reject the claim. If accepted, they will pass the claims to the Adjudication Department, where they will either be paid or denied.
Important: When a claim is with the payer's EDI department, the payer's Customer Support will have NO ability to access the claim. If the claim is with the EDI, then Customer Support will have to wait for the claim to reach adjudication BEFORE they, or you, can view it.
It's common practice for any insurance company to have their EDI and Adjudication/support systems completely separated. One cannot access the other, which causes much confusion and frustration, but this is something to expect with all insurance companies.
How do I Fix This?
Payers have up to 30 days to make a decision once they have accepted a claim. If a claim has been in an Accepted status for more than 30 days, please contact Apex support. We will contact the payer's Clearinghouse or EDI for more information, then notify you of what is needed to continue. Often times the issue is that the claim was rejected, but the rejection report was never sent to Apex EDI.
You can contact our support team at 800-840-9152 or firstname.lastname@example.org.
How can Apex Fix This?
We are very understanding that this is not an ideal situation, and calling the payer to follow up on a claim can be incredibly time consuming. Unfortunately, without any payer report sent to Apex, we will have no way of accessing the claim's status. There are many cases where the fault lies with the insurance, and we are unable to do anything to change this. We appreciate your understanding that ultimately, Apex EDI cannot change anything with how the payer both processes their claims nor when their status updates aren't being sent.