Check the status of a specific claim

For: Practice Admin · Time: 1–2 min · Frequency: Whenever a patient calls about insurance

Trigger

A patient called asking "did my insurance pay?" or "why am I getting a bill?" — or you need to answer a payer's audit question.

Outcome

You know exactly where a specific claim sits: submitted, paid, denied, still in process. You can tell the patient what happened (or you have enough info to ask the agency).

Where

• RCM → Claims tab
• Claim Detail
• Patient Detail

Steps

1. Find the claim. Two paths:
   • Via patient: Patients → search name → click → see all claims for that patient.
   • Via claim list: RCM → Claims → search by claim number, patient name, or DOS.
2. Read the status pill on the claim row:
   • Draft / Ready — not yet submitted (agency is still working on it).
   • Submitted / Acknowledged — sent to clearinghouse and accepted.
   • In Process — payer is reviewing (typical wait: 14–45 days).
   • Paid — payer paid. Click in to see how much, on what date.
   • Partial Paid — payer paid some; balance is being worked.
   • Denied — payer denied. Click in to see why.
   • Patient Responsibility — insurance done, balance is now the patient's.
3. Click the claim to see detail. The detail page shows:
   • Timeline (submitted → ack → in_process → adjudicated)
   • Line items with billed, allowed, paid, adjusted, balance per CPT
   • Insurance payments posted
   • Denials with reason codes (and whether the agency is appealing)
   • Patient statements sent (if any)
4. For paid claims, the most useful field is Paid Date. That's when the payer's payment was issued (often a few days before the practice's bank received it).
5. For denied claims, the most useful field is the denial reason (CARC/RARC code with description). Common ones:
   • CO-50 Not medically necessary — agency typically appeals
   • CO-29 Time limit for filing has expired — too late, write-off
   • CO-45 Charge exceeds fee schedule — normal contractual adjustment, not a true denial
   • PR-1 Deductible amount — patient's deductible; patient owes
   • CO-22 Coordination of benefits — secondary insurance issue
6. If you can't tell what's happening, message the agency. Use the Notes or Communication Logs on the claim — tagged messages reach the agency faster than email.

Watch-outs

• Status is real-time but adjudication is not. A claim showing "in process" today may have been actually paid 3 days ago — the payer just hasn't sent the ERA yet. Don't promise patients refunds or final answers until the ERA posts.
• Patient balance ≠ what the patient owes the agency. The patient's patient_balance on a claim is what they owe AFTER insurance. Whether the practice (or agency) has actually billed it is a separate question — check Statements tab.
• Denials get reworked. A claim shown as "denied" today might be "appealed" tomorrow and "paid" 30 days later. Check back periodically rather than telling the patient "denied, final."
• Old claims may not be in V2. If the agency only started using Credentik recently, claims from before that aren't here. Ask the agency for historical data.

Related jobs

• Verify a patient's eligibility — same patient, prevent the next claim problem
• Review what your patients owe — broader view of patient balances

Something on this page doesn’t match what you see in the app? Email support@credentik.com and we’ll fix the guide.