Why is this claim "Pending"?

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"™

Patient Advocate, Certified Mediator

AdvimedPro

January 23, 2025

A fair number of claims cannot be processed and finalized by insurance companies. These are called “pending”.

Why are they “pending”? Are there solutions? Let’s dive in.

A. The Meaning of "Pending"

1. The term “pending” essentially means that:

·      The charges cannot be processed

·      A final Explanation Of Benefit cannot be issued

·      Financial responsibility of the 3 parties involves cannot be established. The 3 parties are: the medical provider, the patient and the insurance itself.

2. The normal claim process is simple:

Services are rendered. An invoice or “claim” is generated and forwarded/submitted to the insurance. The Claims dept processes the charges according to the terms of coverage, medical policies, legal mandates, resulting in an Explanation Of Benefit which determines financial responsibilities.

3. But...

If a piece of information is missing or incorrect, or if documentation was not submitted when it should have, that process comes to a stop.

Because of legal requirements forcing insurances to produce EOBs for every claim submitted, a “pending” EOB is generated, until the time comes for that claim to be finalized, either when the needed information/document is received, or when the time limit to receive them has been reached without a response.

B. Causes for “pending” claims

1. Providers’ side:

·      Incorrect, invalid or missing codes (for procedures, diagnosis, place of service, etc)

·      Incorrect patient or subscriber Demographics (date of birth, insurance ID#...)

·      Missing documentation (medical records)

·      Missing info (authorization number, provider Identification #...)

2. Patients’ side:

·      Eligibility issues (including non or late payment of premiums)

·      Questionnaire not returned (accident details, whether Workers’ Comp, potential third party liability)

·      Unclear Coordination Of Benefit: is there coverage with another carrier? Is Medicare involved? Which carrier is primary?

·      Invalid invoicing: a problem for a lot of Out Of Network services, when the invoice given by the medical provider lacks all the codes and info needed for the insurance system to process it.

3.Whose responsibility is it?

It depends! While too many providers and offices will tell patients “it’s your insurance, you deal with it”, patients expect "Pending" claims issues to be resolved by the office that may have created them.

C. Solutions

The good thing is that the reason a claim is “pending” will be the reason it is processed and finalized. Find the missing piece of the puzzle and the claim processing machine will run smoothly.

1. Patients

·      Do return any questionnaire, even if makes little sense or may not apply, in your opinion. Some carriers will automatically request other coverage info once a year, send a form letter for every ER visit or if you turn 65.

·      Return those forms promptly to avoid timeliness denials.

2. Providers

·      In Network providers MUST respond directly to any request for clarification or documentation.

·      Out Of Network providers, however, are not bound to respond to any insurance request, let alone submit any claim on your behalf

·      Out Of Network providers, however, should give you the necessary info, documents or medical records so that you can comply with any request in a timely and effective manner.

3. Insurances

·      A call to your insurance should clarify what exactly was requested from whom and when. A notice sent to an Out Of Network provider has little chance of a response, but you might handle it instead.

·      Following up with your insurance to confirm receipt of the requested info/form/medical records and that the claim is being reprocessed is good practice.

In conclusion:

Merely resubmitting a “pending” claim will only result in a rejection as a “duplicate”, while ignoring any request or questionnaire will ultimately result in a denial… and a bill to you.

As far as following up that all parties are doing their job is concerned, I would do so, to ensure processing, and expedite payment.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

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