Claim in Process

Claim in Process – Simple Explanation for Medical Billing

When a claim status shows “Claim in Process”, it means the insurance company is still working on the claim and has not completed processing yet.

This usually happens when:

• The claim is still within the normal processing time (TAT), or
• The insurance company needs additional information from the provider or the patient.

What is TAT (Turn Around Time)?

TAT is the amount of time taken by the insurance company to process a claim.

Important rule:
TAT is always calculated from the claim received date, not the submission date or service date.

When You Call Insurance – Claim in Process Flow

When insurance says “Claim in Process”, follow these steps:

Step 1: Ask the Received Date

• Ask: “When did you receive the claim?”

Step 2: Ask the Normal Processing Time

• Ask: “What is your normal processing time or TAT?”

Step 3: Calculate TAT

• Calculate the number of days from the received date.
• Check whether the claim is within TAT or crossed TAT.

If the Claim is Within TAT

• Do not take any further action.
• Ask for:
  • Claim number
  • Call reference number
• Set a follow-up for the remaining TAT days.

If the Claim Has Crossed TAT

Ask the insurance:

• “What is the reason for the delay?”

The delay reason usually falls into one of the following categories:

1. Information Requested from Provider

• Ask:
  • What documents or information are required?
• If documents are available and you have permission:
  • Send them to insurance (fax or address).
• If documents are not available:
  • Assign the claim to the correct department or client.
• Always collect:
  • Claim number
  • Call reference number

2. Information Requested from Patient

If a Letter Was Sent to the Patient

• Ask:
  • When was the letter sent?
• If less than 1 month:
  • Do not bill the patient.
  • Set follow-up for 1 month from the letter sent date.
• If more than 1 month:
  • Release the claim to the patient.

Note: Always follow client-specific instructions. Some clients may not require a full one-month wait.

If a Letter Was NOT Sent to the Patient

• The claim can be released to the patient immediately.
• Capture:
  • Claim number
  • Call reference number

3. Other Reasons (Backlog)

• Backlog means the insurance has a high volume of claims.
• Action:
  • Set a follow-up for additional days.
  • Take claim number and call reference number.

Special Case: Claim Pending Due to Litigation

• If insurance says the claim is pending due to litigation:
  • Resolution takes a longer time.
  • It depends on court decisions.
• Action:
  • Document the status.
  • Set follow-up as per client guidelines.

Key Points to Remember

• Always calculate TAT from the received date.
• If within TAT → Follow up only.
• If crossed TAT → Identify delay reason and act accordingly.
• Never bill the patient before waiting the required time when information is requested from the patient.
• Always note:
  • Claim number
  • Call reference number