Insurance Claim Status Follow-Up

What triggers this workflow: Claim status follow-up runs on a weekly cadence. Once a week, the full outstanding claims aging report is reviewed. In addition, any claim that has reached a follow-up date set in a prior cycle is worked immediately, regardless of the weekly schedule.

The follow-up interval structure: Every unpaid claim is checked at defined intervals. A common structure:

• Day 15 from submission: first status check
• Day 30: second status check if not paid
• Day 45: third check; escalate if still unpaid with no clear reason
• Day 60 and beyond: priority escalation; check timely filing deadline immediately

Timely filing deadlines are contractual deadlines after which a claim cannot be accepted. The interval structure above reflects a standard approach used in dental revenue cycle management; practices should calibrate intervals to their payer mix and staffing capacity.

How to check claim status: Check status through the clearinghouse first, as this is fastest. If the clearinghouse does not have a status update, check the payer portal directly. Document the result in the claim record with the date, the source checked, and the status found.

Logging requirements: Every status check must produce a log entry: date checked, source (clearinghouse or payer portal), status found, next action, and next follow-up date. This logging is what makes the workflow auditable and what prevents the same claim from being forgotten again after a status check.

Routing on different outcomes:

• In process or pending: Set a next follow-up date at the next interval. No further action.
• Denied: Route immediately to the denial management process. A denial is not a conclusion; it is the start of an appeal decision.
• Approaching timely filing deadline: Escalate to the billing lead for priority handling. The timely filing deadline is the hard limit; missing it converts a recoverable claim into a permanent write-off.
• Paid: Verify that the payment amount matches the expected amount (contracted fee less applicable adjustments). Route underpayments to the adjustment review process rather than posting as fully paid.

The timely filing calendar: Each payer has its own timely filing deadline (commonly 90, 180, or 365 days from date of service). A timely filing calendar, a reference document listing the timely filing deadline for each major payer, is a required reference for this workflow. Any claim approaching its deadline is immediately prioritized, regardless of where it falls in the regular follow-up queue.

Weekly reporting: The claim status follow-up workflow should produce a weekly summary: total claims worked, claims outstanding over 45 days (with reasons), and any claims approaching timely filing deadlines. This report is reviewed by the billing lead or office manager.