What are Status and Status Reasons

The system applies a status and status reason to every claim. The status indicates the state or condition of the claim. The status reason provides additional information as to why the claim is in that state.

A user can view the claim's status/status reason on various pages throughout ZOLL Billing.

Here are some examples of status/status reason combinations:

• Closed - In collections
• Follow-up - Balance after refund
• Suspended - Verify COB
• Suspended - In state debt collections

Changing a status and reason

On the Claim page, click the edit icon next to the status and status reason and then select one from the list.

You can change the status and reason on your claim whenever you want, with these exceptions:

• Some status/status reasons are set by the system and cannot be changed (see the table below).

• Once a claim is complete, you cannot move it back to Incomplete.

• Once a claim has been billed, you cannot cancel it. The AR is on the books and if that is not right, then adjust off the balance.

• You cannot close a claim with a balance.

• You can’t move a claim to Credit Posted because that’s a pass through status and not a status your claim can sit in.

Overriding next payer/status

The payer and claim status can be overridden on the Transaction Details page (including 835 transactions). At the bottom of the page, under the "Next payer and status" heading, you will find two fields:

• The first field will allow you to select the payer. When clicked, a list will display the payers from the COB, including the patient and the facility (if one exists on the COB). The payers will display in the order they exist on the COB (i.e. primary payer will display first, secondary payer second, etc.). If you move to a previous payer, the claim status field will default to the status associated with that payer unless the payer has not yet been billed. In that case the status will default to "Queued for submission" with the same override options as on the claim.

• The second field will allow you to select the claim status. The color of the field's boarder will reflect the status you select.

There are several instances where you cannot change the payer or status:

• The claim is in collections or state debt

• The claim's balance is zero

• Closed cannot be selected as a status

List of status & status reasons

The following table contains a list of all the statuses and their corresponding status reasons. A "yes" indicates that you can change this status and status reason combination to another combination. A "no" indicates the status and status reason combinations that are set by the system and therefore cannot be changed. You can search items within this table by entering the name in the search field. For example, if you want to see all the changeable statuses, enter "yes" in the search field. To see a specific status, enter the status name in search (i.e., Follow-up).

Status name	Reason	System sets = User can set =
Appealed	ALJ	- yes
Appealed	Appeal unresolved	- yes
Appealed	Payer reprocessing	- yes
Appealed	Phone appeal	- yes
Appealed	Reconsideration	- yes
Appealed	Redetermination	- yes
Appealed	Written appeal	- yes
Canceled	Duplicate claim	- yes
Canceled	Mutual aid service	- yes
Canceled	Patient deceased	- yes
Canceled	Patient is a city employee	- yes
Canceled	Patient is a prisoner	- yes
Canceled	Patient not found	- yes
Canceled	Patient refusal	- yes
Canceled	Unbillable	- yes
Closed	Balance resolved	- yes
Closed	In collections	- no
Closed	Payer paid the patient	- yes
Closed	Refund	- no
Closed	Review non-collections activity	- no
Closed	Write-off (full)	- no
Closed	Write-off (partial)	- no
Credit posted	Collections fee	- no
Credit posted	Payment	- yes
Credit posted	Payment reversal	- no
Credit posted	Refund	- no
Credit posted	Refund adjustment	- no
Credit posted	Revenue adjustment reversal	- no
Credit posted	Take back	- no
Credit posted	Write-off	- no
Credit posted	Write-off reversal	- no
Denied	Appeal needed	- no
Denied	Appeal request rejected	- no
Denied	Denial unresolved	- yes
Denied	Denial upheld	- no
Denied	Full denial	- no
Denied	Partial denial	- no
Denied	Payer reprocessing	- yes
Follow-up	Account review	- no
Follow-up	Balance after adjustment	- no
Follow-up	Balance after refund	- no
Follow-up	Balance after refund reversal	- no
Follow-up	Balance after take back reversal	- no
Follow-up	Balance forwarded	- no
Follow-up	Charges corrected after submission	- no
Follow-up	Clinical documentation requested	- yes
Follow-up	Credit balance	- no
Follow-up	Credit from ineligible payer	- no
Follow-up	Deductible variance	- no
Follow-up	In medical review	- yes
Follow-up	LOA overpayment	- no
Follow-up	LOA underpayment	- no
Follow-up	No response from payer	- no
Follow-up	Overpayment	- yes
Follow-up	Patient involvement needed	- yes
Follow-up	Payer paid the patient	- yes
Follow-up	Payer reprocessing	- yes
Follow-up	Payment activity against obsolete charge	- no
Follow-up	Payment move requested	- yes
Follow-up	Payment moved	- no
Follow-up	Payment plan not met	- yes
Follow-up	Payment promised	- yes
Follow-up	Payment reversal	- no
Follow-up	Payment review needed	- no
Follow-up	Reconsideration	- yes
Follow-up	Refund requested	- yes
Follow-up	Review non-collections activity	- no
Follow-up	Review requested	- no
Follow-up	Take back	- no
Follow-up	Take back (pending)	- yes
Follow-up	Un-adjudicated	- no
Follow-up	Underpayment	- yes
Follow-up	Verify COB	- yes
Incomplete	Charge needed	- yes
Incomplete	Coding needed	- yes
Incomplete	Facility needed	- yes
Incomplete	New claim	- yes
Incomplete	Payer needed	- yes
Incomplete	Verify patient account *This status only displays for imported claims that need patient verification. After the information is verified, the claim is created and the status changes to Incomplete - New claim.	- no
Queued for submission	Clearinghouse	- yes
Queued for submission	Facility invoice	- yes
Queued for submission	Manual submission	- yes
Queued for submission	New claim	- yes
Queued for submission	Patient statement	- yes
Queued for submission	Resubmit statement	- no
Submitted	Auto crossover	- yes
Submitted	Clearinghouse	- no
Submitted	Facility invoice	- yes
Submitted	Final statement sent	- no
Submitted	Manual submission	- no
Submitted	Manual upload	- yes
Submitted	New claim	- no
Submitted	Patient statement	- yes
Suspended	Account locked	- no
Suspended	Account review	- no
Suspended	Adjustment needed	- yes
Suspended	Adjustment requested	- yes
Suspended	Auth appealed	- yes
Suspended	Auth denied	- yes
Suspended	Auth primary needed	- yes
Suspended	Auth requested	- yes
Suspended	Auth secondary needed	- yes
Suspended	Charge needed	- yes
Suspended	Claim against estate filed	- yes
Suspended	Claim against estate needed	- yes
Suspended	Clearinghouse	- no
Suspended	Clinical documentation needed	- yes
Suspended	Clinical documentation received	- yes
Suspended	Clinical documentation requested	- yes
Suspended	Coding needed	- yes
Suspended	Collection letter sent	- yes
Suspended	Credit balance	- no
Suspended	Designation changed	- no
Suspended	Diagnosis review needed	- yes
Suspended	Doc packet needed	- yes
Suspended	Eligibility check needed	- no
Suspended	Eligibility checks not available for payer	- no
Suspended	Face sheet requested	- yes
Suspended	Facility needed	- yes
Suspended	Failed validation	- no
Suspended	Final statement sent	- no
Suspended	Hold for deductible	- yes
Suspended	Hold for retroactive Medicaid	- yes
Suspended	In state debt collections	- no
Suspended	In active coverage	- no
Suspended	Insurance needed	- yes
Suspended	LOA needed	- yes
Suspended	LOA pending	- yes
Suspended	Medicaid pending	- yes
Suspended	Medical necessity appeals	- yes
Suspended	Medical records request	- yes
Suspended	Network approval needed	- yes
Suspended	Next payer needed	- no
Suspended	Past timely filing	- yes
Suspended	Patient address needed	- no
Suspended	Patient agreement needed	- yes
Suspended	Patient bankruptcy	- yes
Suspended	Patient covered by Medicaid	- yes
Suspended	Patient deceased	- yes
Suspended	Patient grievance	- yes
Suspended	Patient is a member	- yes
Suspended	Patient is homeless	- no
Suspended	Payer address needed	- no
Suspended	Payer needed	- yes
Suspended	Payment plan disabled	- no
Suspended	PCR addendum needed	- yes
Suspended	PCS needed	- yes
Suspended	PCS requested	- yes
Suspended	Pending legal	- yes
Suspended	Pre-determination needed	- yes
Suspended	Referral needed	- yes
Suspended	Refund needed	- yes
Suspended	Review new claim	- yes
Suspended	Signature needed	- yes
Suspended	Verify claim balance	- no
Suspended	Verify COB	- yes
Suspended	Verify coverage	- no
Suspended	Write-off pending	- yes