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Provider Manual

Claim Status Definitions

Last Updated on January 24, 2019

Unfinalized Status Options

  • ADJUDICATED (ADJUD): The claim has been adjudicated but is not ready for payment.
  • DENY: The claim has either failed adjudication or has been pended for manual review and is not ready to be submitted for payment.
  • OPEN: The claim is currently being processed but has not been adjudicated.
  • PAY: The claim has passed the adjudication process and is ready to be submitted for payment.
  • PEND: The claim has been set aside for review to determine if it should be paid or denied.
  • REV: The claim has been processed and paid with an over or under payment error. A mirror image of the claim has been created to correct any payment errors.

Wait Status Options

  • WAITDENY: The claim has been submitted for payment, but payment processing is not complete. After payment processing is complete, the claim status is updated to DENIED.
  • WAITPAY: The claim has been submitted for payment, but payment processing is not complete. After payment processing is complete, the claim status is updated to PAID.
  • WAITPRICE: The claim has been priced by an external entity and has been returned to QNXT as a HIPAA 837 transaction. After the claim has been imported back into the QNXT environment, the status is updated to WAITPRICE to designate it for repricing.
  • WAITREV: The claim has been submitted for payment, but payment processing is not complete. After payment processing is complete, the claim status is updated to REVERSED.

Finalized Status Options

  • DENIED: The claim has failed the adjudication process and has been denied.
  • PAID: The claim has been finalized and submitted for payment. Checks have been printed and the payment process is complete.
  • REVERSED: The claim has been finalized. Checks have been printed and the payment process is complete, but errors have been identified and a mirror image of the claim has been created to correct the errors.