Behavioral Health Claim Status Simulator

Which team should take the next action?

Each fictional claim comes from an outpatient treatment program and has an open task. Read the available evidence, choose a queue, and check the next action. The exercise uses sample records only.

What evidence separates a rejection from a denial?

A rejection is reported during claim submission or processing edits. A denial is an adjudication outcome. An unpaid claim can also be awaiting a response or have a posting issue. Start with the latest verified response and confirm it belongs to the claim in question.

Local hold

The draft claim is held for a missing signature. The submission log has no send event for this claim. Example owner: Encounter reviewer.

Missing acknowledgment

The submission log shows the claim was sent. The expected claim-level acknowledgment is missing for the recorded submission reference. Example owner: Submission follow-up.

Submission rejection

A claim-level acknowledgment identifies this claim as rejected and points to a required submission field. Example owner: Claim correction reviewer.

Pending payer review

The claim-level acknowledgment shows acceptance. A later payer status response reports the claim is still in process. Example owner: Payer follow-up.

Adjudicated denial

The payer remittance lists this claim as denied and includes adjustment information for the service line. Example owner: Denial reviewer.

Posting exception

The remittance and matched deposit both include the payment. The payment is missing from the expected claim ledger. Example owner: Posting and reconciliation.

CMS describes these records for Medicare claims. Confirm the acknowledgments and status responses used by your own clearinghouse and payer.

• Medicare electronic claims edits and responses
• 276/277 claim status inquiry and response
• 835 payment and remittance advice