Overview
The Claims Dashboard for Workflow Services (WS) is a tool designed to help pharmacists efficiently track the status of claims, both for cash services and insurance-billed claims. This dashboard provides an intuitive interface that displays the real-time status of each claim, allowing pharmacists to monitor progress of each claim.
The following article describes the different claim statuses you will see on the Claims Dashboard, their meanings, and how they fit into the overall claims process.
Claim Statuses
The Claims Dashboard uses a set of distinct status indicators to help you track where each claim is in the processing workflow. These are the primary claim statuses you will encounter:
1. Pending
- Meaning: A workflow has been initiated for the patient, but the claim has not yet moved forward for review or processing.
- What it means for you: The claim is in the early stages of being generated. It indicates that a workflow has been started for a patient but not yet completed.
2. Ready
- Meaning: The Review Billing screen is complete, and the claim is now ready to be reviewed by the Workflow Services team.
- What it means for you: All billing information has been entered and the claim is now in a state where WS can assess its readiness for submission.
3. Submitted
- Meaning: WS has sent the claim to the payer for review.
- What it means for you: The claim is now in transit to the payer. The clearinghouse acts as an intermediary to ensure the claim is formatted correctly and compliant with payer requirements before it is submitted for payment or denial review.
4. Failed
- Meaning: The claim could not be processed due to issues such as incorrect message types or billing codes.
- What it means for you: The claim has failed to meet the requirements for submission to the payer, often due to data errors such as wrong billing codes, formatting issues, or invalid claim types.
- What we do: WS will automatically address these issues by correcting the claim's details.
5. In Collection
- Meaning: An ERA (Electronic Remittance Advice) has been received, and the amounts paid and amounts owed are being posted.
- What it means for you: The payer has reviewed the claim and issued payment or communicated the amount due. The claim is now in the collection phase, where payment amounts are being reconciled, and patient balance information is updated. We encourage you to follow up with patients on outstanding balances whenever appropriate and update the claim status once collection efforts are complete. NOTE: There are ways to close a claim beyond collecting payment directly through Workflow Services. For example, if payment was collected through your pharmacy's POS system, you can indicate that within the claim and close it appropriately. Keeping claim statuses up to date helps ensure your records stay accurate.
- What we do: WS reviews the ERA to confirm the payment details. If there are discrepancies, such as underpayments or denials, we follow up with the payer. We ensure that patient balances and insurance payments are accurately reflected in the system.
6. Expiring
- Meaning: Claims that remain in In Collection status for 90 days automatically move into Expiring status.
- What it means for you: This gives your team a final 7 day window to review the claim and take any necessary action, such as confirming collection or closing it manually, before it's handled automatically. You will receive a weekly medical billing summary email highlighting aging claims, so your team can review and act on them before this happens.
- What we do: If no action is taken within the 7 day Expiring window, the claim is automatically marked as Paid and the associated Workflow Services service fee is invoiced to the pharmacy.
7. Paid
- Meaning: The patient balance has been paid, or if there is no balance due, the claim is marked as paid. A claim will also move to Paid automatically if it times out of the Expiring status without action.
- What it means for you: The claim has been fully processed, and any remaining patient balance has been paid. For claims with no outstanding balance, the status will still show as "Paid."
- What we do: Ensure the payment has been received and properly posted to the claim. If there are any outstanding balances that are still owed by the patient we automatically charge the credit card on file.
8. Completed
- Meaning: All work on the claim has been finished, and no further action is required.
- What it means for you: The claim has successfully passed through all stages of the workflow. All actions have been completed, including payment reconciliation, patient billing, and any necessary follow-up.
9. Denied
- Meaning: The claim was submitted but was not approved for payment by the payer. This may be due to missing information, coverage issues, or clinical ineligibility.
- What it means for you: The service associated with this claim was not covered or reimbursed by the payer. Depending on the denial reason, the patient may be responsible for the full amount, or the claim may need to be corrected and resubmitted.
- What we do: For in-network claims and claims generated using our native workflows, we review the denial reason and take appropriate action—whether that means correcting and resubmitting the claim, or notifying the pharmacy and patient of next steps. If the patient becomes responsible for payment, we will attempt to collect the balance using the credit card on file and notify them accordingly. Out-of-network claims or claims generated from a template created by the pharmacy using the CVT builder will not be investigated by Workflow Services.
10. Returned
- Meaning: The claim has been returned to the provider to review and update for resubmission.
- What it means for you: It is your responsibility as the provider to make the necessary updates to these claims. Click the pencil icon on the claim, and you will see Notes as to why the claim was returned. Fix whatever needs to be updated, and resubmit the claim into a ready status.
- What we do: Once it's returned, reviewed by you, and sent to a ready status, we will review and resubmit the claim for you.
11. Unprocessable
- Meaning: The claim cannot be processed, usually because it is incomplete and the needed data is not recoverable, or it is outside the timely filing window.
- What it means for you: No further action is required on this claim. It has been reviewed and determined that it will not be reprocessed.
- What we do: We mark the claim as Unprocessable to close it out while preserving a complete record of every claim that has been initiated. Claims in this status require no additional work and will not be resubmitted.
How to Use the Claims Dashboard
The Claims Dashboard is designed to help you easily manage the claims process. Here’s how to make the most of it:
- Track Claim Statuses: View the status of each claim in real-time. Claims will be listed by their current status, allowing you to see where each one stands in the process.
- Review Weekly Summary Emails: Your team will receive a weekly medical billing summary email highlighting aging claims, so you can review and act on them before any automatic status change occurs.
- Sort and Filter Claims: You can sort claims by status, date, or patient name, helping you quickly find and prioritize specific claims.
- Monitor Payment and Reimbursement: For claims that are in the "In Collection," "Expiring," or "Paid" stages, monitor payments and ensure proper posting of amounts owed by patients or received from insurance.
Conclusion
The Claims Dashboard for Workflow Services is an essential tool for pharmacists to effectively track and manage claims. By understanding the different claim statuses and how they fit into the workflow, you can ensure claims are processed efficiently and that payments are received in a timely manner. Whether you are dealing with insurance claims or cash services, the dashboard allows you to stay informed at every stage of the process.
For any additional help or questions regarding claim status updates, please contact support@imagemovermd.com for assistance.