Claim Statuses

Explore different statuses for insurance claims.

There are currently 11 different statuses that insurance claims can be categorized in Zencare. Each status communicates where a claim is in its process from Ready to Submit to the end of its process cycle, whether that is Approved, Denied, Rejected, or Voided. Below you will find a list of these statuses and the actions you can perform for each.

You can find the current status of any insurance claims you have made on the right hand side of the Unadjudicated Claims and Adjudicated Claims view in the Workflow category and in the Insurance section of a specific client's profile under the Clients category.

Claim Statuses

• Ready to Submit: A claimable session where a claim has not been submitted for yet and is ready for claim creation. This status is for a client with insurance coverage and has been marked attended and invoiced. The therapist on the session must have an insurance profile with an accurate NPI, Taxonomy code, and address.
• Queued: The claim has been submitted and has been queued for submission to the claim clearinghouse.
• Submitted: The claim has been submitted to the clearinghouse for audit and submission to the insurance payer.

• Corrected: A claim that has been Rejected or Denied and you have selected the Edit Claim action, resubmitting the claim back through the submission process with edits to the original claim based on the rejection or denial reasons.
• Rejected: The claim has been submitted to the clearinghouse, audited, but did not pass the audit. The claim has not been submitted to the insurance payer and has been returned with the reason for its rejection. If you receive a Rejected claim, you can view the rejected reasons by hovering your mouse over the Rejected status in the Claims table.
• Approved: The claim has passed the clearinghouse, has been received and processed by the insurance payer and claim adjudication has been finalized with an outcome of Approved. The payer will/has issued a payment for their portion of the client's coverage plan.
• Deductible: The claim has passed the clearinghouse, has been received and processed by the insurance payer and claim adjudication has been finalized with an outcome where the claim is approved. However, due to the client's plan type, their insurance will not be issuing a payment and the balance is applied to the client's deductible.
• Denied: The claim has been submitted to the clearinghouse, passed the clearinghouse audit, submitted to the insurance payer, and adjudicated as Denied by the payer. Denials can be for any number of reasons deemed by the insurance payers plan.
• Voided: For when you have voided the claim for any reason at any point in the claim processing cycle.
• Replacement: This status indicates a new claim has been submitted into the claim process that is a replacement for a prior claim denial. The original claim has been Denied and you have voided the original denied claim. A new "replacement" claim has been created, populated with the original claim ICN, and the submission code has been updated to '7 - Replacement of prior claim'.

User Actions by Claim Status

The following is a table of actions you can take depending on the current claim status. Check marks denote that an action can be taken under the given claims status, and X marks denote that an action cannot be taken under the given claims status.