Working the claims queue

The claims queue is your day-to-day insurance worklist. In the left sidebar, under Admin, click Claims. You can also work with one patient's claims: in the left sidebar, click Patients, click the patient's name, then click Claims in the patient chart sidebar.

How do I find claims to work?

In the left sidebar, under Admin, click Claims to see claim volume by status, then narrow the queue to the claims you need to handle.

Claims are grouped by status, and each group shows a count. The list uses a two-line layout instead of fixed columns. Select a row to open the claim. Use List (1) when you want to work claims in order. Use Board (2) when you want to see claims by workflow bucket. Status (3) filters the queue by payer stage, and More filters (4) opens the rest of the filters.

Filter by Status (3), Bucket, case, patient, payer or date. Use Search claims (1) to find a specific claim, Updated (2) to narrow by when it changed, and More filters (4) for the remaining filters. The date filters are inline Service from and Service to fields, plus Updated from and Updated to fields. Status is the payer or clearinghouse stage. Bucket is your team's internal workflow lane. When you filter by case, a Case chip appears and you can remove it from the filters bar.

The available buckets are Untriaged, Review, Hold, Open / Payments, Open / Pending, Open / Settled, Patient Billing and Closed.

Owners and admins can select Manage billing rules (5) from the filters area to manage claim-scrubbing rules. Staff can work the claims queue, but Settings pages such as billing rules are limited to owners and admins.

How do I submit draft claims?

On the same page, use the draft queue when a draft is ready to leave the draft queue.

1. In the left sidebar, under Admin, click Claims.
2. Open the Draft (2) group.
3. Review the claim's patient, payer, diagnoses, service lines, claim providers, attachments and charge amount in the Claim row (3).
4. Open the Claim actions (4) menu.
5. Select Submit claim.
6. To send more than one draft, use Select and Submit (5) in the Draft group and choose the drafts you want to send.

The claim is submitted, and later payer or clearinghouse updates appear on the claim.

In the draft, Claim providers can include separate Referring, Supervising and Ordering roles. Prints in Box 17 shows which provider role will print on the CMS-1500; the electronic claim carries all of them. Service lines can also show drug NDC details when they are available. Draft editing can also show case-linked fields, and the claim detail area can show a Case row when the claim belongs to a case.

The resubmission area uses Resubmission code (22) and Payer's claim number / ICN (22). A draft with blocking validation errors cannot be submitted until the errors are fixed. If a date field is half-typed or invalid, save and submit stay blocked until you fix it. If the patient has no insurance on file, the draft shows a claim error and may offer Add patient insurance. Submit claim stays visible but disabled until the insurance issue is fixed.

If you open a claim from an archived patient's chart, the action buttons in the queue and detail panel are disabled. You can still view the claim, open the PDF and use history.

How do I read a claim?

On the same page, select a row to review what was sent, what came back and what still needs work.

The Details tab (1) shows the claim status, patient, payer, member ID, billed amount and service information. It also shows diagnosis codes, service lines and CMS-1500 sections such as Payer & member, Patient, Insured, Condition related, Claim providers (5), Service facility, Billing provider, Signatures & assignment and Additional claim info. The detail panel can also show a Case row when the claim belongs to a case. Claim providers (5) separates Referring, Supervising and Ordering providers and shows which one Prints in Box 17. Service lines can also show drug NDC details when they are available.

Submitted claims also show Sent as for Box 22.

Submitted claims also show a read-only Attachments summary when the claim has attachments. The same panel can show claim alerts, payer or clearinghouse messages, payment amounts and patient-balance information when those details are available. Use Claim PDF (3) when you need a CMS-1500 copy for printing or outside follow-up. Use History (2) to review claim activity, and the version navigator (4) to move through saved claim versions.

If you open a claim from an archived patient's chart, the action buttons in the queue and detail panel are disabled. You can still view the claim, open the PDF and use history.

How do I understand claim statuses?

On the same page, use the status groups to understand where the claim is in the payer or clearinghouse process.

Use List view (1) to read the queue as a list, then compare Draft status (2), Rejected status (3) and Paid status (4) with the table below.

Status	What it means
Draft	Built but not submitted. Drafts can still be edited.
Submitted	Sent through the claim submission flow.
Acknowledged	Receipt was acknowledged. This is not a payer decision.
Accepted	Accepted for payer processing.
Rejected	Stopped before adjudication, usually because something must be corrected and sent again.
Denied	Adjudicated and refused by the payer. Work the denial rather than treating it like a formatting rejection.
Paid	Payment was received or posted.

The Draft (1) and Rejected (2) groups are the ones you will usually work first. Status filters (3) narrow the list to one or more payer stages, and Board view (4) switches the queue to workflow buckets.

The Rejected and Denied difference matters. A rejection usually means the claim did not make it through cleanly. A denial means the payer reviewed it and refused some or all of the charge. In the queue, each row now uses a two-line layout instead of separate payer, paid and patient-share columns.

How do I find why a claim was rejected or denied?

On the same page, open the claim and review its Details before deciding what to fix.

The Details tab can show alerts and messages from validation, the clearinghouse or the payer. Alerts are grouped as errors, warnings or notes. Some validation alerts can take you to the related claim field so you know where to correct the draft.

When remittance information is available, the payment section separates paid, patient, writeoff and denied amounts. Denied service lines can show denied amounts and adjustment codes. The remittance section can also show entered-by-hand rows without a download button and a visible remittance reference when that information is present.

How do I use claim history and versions?

On the same page, open the claim and use the History tab to audit edits, submissions, payer updates and snapshots.

History entries can include claim creation, draft updates, chart syncs, submissions, resubmissions, payer acknowledgements, payer acceptances, clearinghouse rejections, denials, payments, ERA receipt, secondary claim filing, copay activity, visit copay invoicing, copay returns and card charge scheduled activity. External references may show the connected system and reference number.

Use View snapshot (2) on a history entry when it is available to see the claim as it looked at that point. The History (1) tab shows the timeline entries (3), and the version navigation at the top of the claim lets you move through saved claim versions.

If you open a claim from an archived patient's chart, the action buttons in the queue and detail panel are disabled. You can still view the claim, open the PDF and use history.

What can't I do here?

In the left sidebar, click Claims under Admin. On Claims, access and actions are limited in these ways:

• Clinicians do not get the full operations claims queue unless they also have an Owner, Admin or Staff role.
• If insurance is not enabled for the organization, the claims pages do not open.
• Staff can work the claims queue, but they cannot manage Settings pages such as billing rules.
• A draft with blocking validation errors, including half-typed or invalid date fields, cannot be submitted until the errors are fixed.
• A draft with missing insurance shows a claim error and cannot be submitted until the insurance issue is fixed.
• Once a claim is submitted, it is no longer an ordinary draft. Use the claim's available follow-up actions for corrections, resubmissions and denial work.
• When you open a claim from an archived patient's chart, the action buttons in the queue and detail panel are disabled, including claim details, draft submission, status inquiry, remittance and revert actions, but viewing, the PDF and history still work.

Common questions

Can I work claims from a patient chart?

Yes. In the left sidebar, click Patients, click the patient's name, then click Claims in the patient chart sidebar to see claims for one patient instead of the full organization queue.

What is the difference between status and bucket?

Status reflects the payer or clearinghouse stage, such as Submitted, Rejected or Paid. Bucket is your team's internal workflow label, such as Review, Hold or Patient Billing.

Should I resubmit a denied claim the same way I resubmit a rejected claim?

Not usually. A Rejected claim is usually corrected and sent again because it did not pass cleanly. A Denied claim was adjudicated by the payer, so review the denial details and use the appropriate follow-up process.

Where do I see what changed on a claim?

In the left sidebar, under Admin, click Claims, open the claim, and use the version navigation or History. If an entry has View snapshot, select it to see that saved version.

Where do I manage scrubbing rules?

In the left sidebar, under Admin, click Claims. Owners and admins can select Manage billing rules from the filters area, or open Scrubbing claims with billing rules.

Can I filter claims by case?

Yes. In the claims filters, choose a case to narrow the queue, then remove the Case chip if you want to clear that filter.

Where do I see case-linked fields?

Case-linked fields can show in the draft editor and on the claim detail panel when the claim belongs to a case.