Tracking and Understanding Claim Status
Table of Contents
Tracking a Claim
Tracking claim in Pear Suite helps you monitor where a claim is in the billing process and take action when needed. Each claim moves through different statuses that indicate whether it is being processed, requires attention, or has been completed. Understanding these statuses ensures claims are handled correctly and efficiently.
Claim Status, the Life Cycle and What They Mean
Generated
The claim has been created after an activity was marked as billable and completed. These are marked in Yellow.
Error
The claim contains missing or incorrect information that must be corrected before it can proceed. Hovering over the status will display specific errors that need to be resolved. These are marked in Red.
To Resolve an Error:
- Review the listed issues and update the missing or incorrect information.
- Ensure the claim details match the payer’s requirements.
- Resubmit the claim once all necessary corrections are made.
You can also review the Common Claims Errors and Fixes article.
Ready for Screening
The claim is being review before submission. These are marked in Green.
Approved
The claim has been reviewed, approved, and is ready to be sent to the clearinghouse. These are marked in Green.
Sent
The claim has been sent for processing and is awaiting for the health plan to review. These are marked in Green.
Accepted
The claim has been received and acknowledged by the health plan. These are marked in Green.
Notice: This may not indicate that payment has been made. Be sure to check the paid amount to ensure the claim has a reimbursement. If there is zero dollar reimbursement, there is a possibility the claim has been denied.
Rejected
The claim was not processed due to errors in the submission, such as incorrect coding, missing member details, or formatting issues. A rejected claim can be corrected and resubmitted. These are marked in Red.
Notice: A rejected can be resubmitted, however it does not indicate a decision on whether or not the claim will be accepted.
Denied
The insurance company has reviewed the claim and decided not to pay for it, usually due to policy reasons such as the service not being covered or not meeting medical necessity criteria. These are marked in Red.
Notice: Denied claims may require an appeal or additional documentation to be reconsidered.
Paid
The claim has been successfully processed, and payment has been received. These are marked in Green.
Understanding Claim Status Colors
Pear Suite uses color indicators to help you quickly understand the status of a claim. These colors appear next to each claim and make it easy to identify which ones need attention.
-
Yellow – Generated
This means the claim has been created but still needs to be reviewed or screened. It's not ready for submission yet. Open the claim to check details and make sure everything looks right. -
Red – Error, Change Requested, Denied, or Rejected
These statuses show that something needs to be fixed or followed up on. You’ll need to open the claim, review the issue, and take action. Claims in red are not billable until corrected and regenerated if needed. -
Green – Ready for Screening, Approved, Sent, or Paid
These statuses show that the claim has moved forward in the process. No action is needed unless you're reviewing past submissions or tracking payments.
This color system helps you quickly prioritize claims and reduce the chances of missing items that are stuck or need changes. You’ll see these colors in all claims tables and status views throughout the platform.
By understanding these statuses, you can track your claims effectively and address any necessary actions to ensure they move through the billing process successfully.