Claim Status, Stage & Payer Status

At a Glance

Three fields describe where a claim is and what it needs. Read them in order:

Status — what needs to happen next on the claim, and whether it needs action.
Stage — which party holds the balance right now: a payer or the patient.
Payer status — where the claim stands with one specific payer, either what that payer has said so far or that the payer has not responded yet.

This page defines every value the three fields can take, plus payment status: the icons in a claim’s Payments section that show, for each payer, the patient, and each procedure, what has been paid and who still owes the rest. For the page the three fields appear on, see Getting Started with the Claims Page; to filter and group by them, see Organizing Your Claims Worklist.

Status

Status shows what is currently happening on a claim. It is a single line that tells you whether that claim needs action. A status is workable when you or your Athelas team can act on the claim right now. The statuses that are not workable are waiting on a payer or the patient, moving forward on their own, or already complete. The built-in Workable Claims view combines all three conditions: the claim is your site’s responsibility, its status is one of the workable ones below, and it is not deferred.

Status	What it means	Workable?
Import Errors	The visit could not be fully imported from the EHR. The source data needs fixing before a claim can be built.	Yes
Needs Initial Review	Waiting on a human first pass before the initial claim goes out to the primary payer. This applies to initial submissions only, not to secondary, tertiary, or resubmitted claims.	Yes
Unsubmitted	Ready to be worked toward submission. Nothing has gone out to a payer yet.	Yes
Submission Errors	The claim was blocked before it reached the payer. It failed a pre-submission check or rule, clearinghouse verification, or transmission.	Yes
Rejections	The clearinghouse or the payer’s front-end edits rejected the claim before adjudication, so no payment decision was made.	Yes
Decision Pending	Submitted and waiting on the payer’s decision. Nothing has come back yet.	Yes
Decision Inconclusive	The payer responded, but the response does not settle the claim — a duplicate-claim denial, a claim forwarded to another payer, a placeholder denial with no usable reason code, or every remittance archived.	Yes
Payment Posting	A remittance has arrived and is being posted to the claim, or the claim was posted for more than the payer allowed and needs correcting.	Yes
Full Denials	The payer allowed nothing on the claim.	Yes
Partial Denials	The payer paid some lines and denied others.	Yes
Unresolved Balances	The payer allowed and paid every line, yet a balance is still left on the claim, so the claim has not moved on to the next payer or to the patient. Unlike Partial Denials, no line was denied; the leftover is unexplained or was never transferred.	Yes
Packet Pending	An appeal or medical record packet needs to be generated and submitted. A claim lands here when someone requests an appeal, or when Athelas automation reads the denial codes and decides the claim should be appealed or needs records.	Yes
Statement Generation Pending	The balance is now the patient’s, and Athelas is generating the statement to send to the patient. Nothing for you to do.	No
Awaiting Patient Payment	A statement has gone out and the patient still owes. Athelas is waiting on the patient to pay.	No
No Action Needed	Nothing for you or Athelas to do right now — the payer has the claim and Athelas is waiting on the payer, the claim is queued and will submit automatically, the visit was marked not billable or predates go-live, or the patient has paid in full.	No
Finalized	Every balance on the claim has been accounted for. Payers and the patient have paid, or the remainder was adjusted or written off. Nothing is owed by anyone.	No
Status Classification Failed	The system could not determine a status. Athelas is alerted automatically and will correct the status. Nothing for you to do.	No

Deferred is not a status. Deferring a claim pauses it for up to 90 days without changing its status — the claim drops out of workable views until the deferral expires or its status changes. Claims that enter Decision Pending are deferred automatically for 30 days. See Deferring a Claim.

Stage

Stage identifies which party holds the remaining balance on a claim: a payer, the patient, or no one once the claim is complete.

Stage	What it means
Payer 1	The primary payer is responsible for adjudicating the remaining balance. You are awaiting or working a remittance from that payer.
Payer 2	The secondary payer owns the remaining balance, after Payer 1 has made its decision.
Payer 3	The tertiary payer owns the remaining balance, after both Payer 1 and Payer 2 have made their decisions.
Patient	Every payer has decided, or the visit is self-pay, and what is left is patient responsibility. The patient is expected to pay the outstanding amount.
Finalization Pending	Every balance is settled, but pending or manual-review remittances are still attached to the claim. The claim moves to Finalized once those are posted or archived.
Finalized	Every balance has been accounted for and nothing remains. Payers or the patient have paid, or the rest was adjusted or written off.

Payer Status

Payer status records where a claim stands with one specific payer. A claim carries one payer status per payer rather than a single overall one. Hover a claim’s Stage to see the payer status for each payer on the claim. Read Status first, then Stage. A status of Full Denials tells you the claim was denied; a stage of Payer 2 with a payer status of Denied identifies Payer 2 as the payer that denied the claim. On a multi-payer claim, that distinction tells you which payer to work.

Before the Claim Goes Out

These payer statuses are listed in the order a claim moves through them.

Payer status	What it means
Imported	The encounter just landed from the EHR and has not been evaluated yet. This clears on the next status refresh.
Initial Review Required	Marked billable, but not yet marked ready to submit, so someone needs to review the claim first. Primary payer only.
Missing Procedures	No procedures on the encounter, so there is nothing to bill. Primary payer only.
Missing ICD-10	No diagnosis codes at all, principal or secondary. Primary payer only.
No Patient Insurance	No insurance is recorded at this payer position.
Missing Policy Number	Insurance is recorded at this position but has no policy number.
Duplicate Policy Number	The policy number here is identical to one already used at an earlier payer position.
Insurance Not Mapped	The patient’s insurance record is not linked to a known payer, so the claim cannot be routed. See Payer Mapping.
Unrecognized Insurance	The insurance is mapped to the catch-all “unrecognized” payer rather than to a real one. See Payer Mapping.
Unsupported by CHC	The clearinghouse cannot transmit to this payer, so the claim cannot be sent electronically.
Self Pay	This position is self-pay: there is no payer to bill, only the patient.
Pre Launch	The date of service predates your site’s go-live or backfill date, so Athelas does not bill the claim. Primary payer only.
Inherited AR	A balance carried over from before Athelas took over billing at your site. Primary payer only.
Not Intended To Bill	Flagged as not billable, which pulls the claim out of the error and rejection queues. Primary payer only.
Unsubmitted	A claim exists at this payer but was never queued to go out — a manual or preview claim, or one still in flight before hand-off.
Submission Pending	Everything passed pre-submission checks and the claim is queued to be filed.

After the Claim Goes Out

Payer status	What it means
Submission Success	The claim transmitted successfully through the clearinghouse. The claim can still be rejected before adjudication, and the payer has not responded yet.
Submission Error	The claim was blocked before it reached the payer. It failed a pre-submission check or rule, clearinghouse verification, or transmission.
Rejected	The clearinghouse or the payer rejected the claim before adjudication. A claim stays Rejected while any claim at this payer has a finalized rejection, even if a newer one has been filed.
Voided	A void was submitted for this claim and the payer accepted the void.

After Money Posts

Payer status	What it means
Approved	The payer allowed something. The allowed amount is paid plus copay plus coinsurance plus deductible, and that total is greater than zero.
Denied	The payer allowed nothing.

Payment Status

Payment status is the icon at the start of each row in the Payments section of Claim Context. Hover an icon to see its label. The section has two tables: the top one has a row for each payer plus a Patient row, and Adjudication Detail below it has a row for each procedure. Payment status follows the money: what has been paid, and who still owes the rest. Payer status, above, follows the claim’s progress with each payer. Both tables use the same columns:

Column	What it shows
Charges	The amount billed. On a payer row, it is what was billed to that payer, or to the patient on the Patient row.
Paid	What has been paid. On a procedure row, insurance and patient payments are added together.
PR	On a payer row, what that payer passed on to the next payer or the patient. On a procedure row, the patient’s share of the line.
Adj.	Adjustments, such as contractual write-downs.
Balance	What is still owed. On a payer row, it is the amount still with that payer: not paid, adjusted, or passed on. On a procedure row, it is everything still owed on the line, including the patient’s share.

An ⓘ icon beside a procedure’s PR means the amount is provisional. Insurance hasn’t finished adjudicating, or the claim isn’t balanced, so the patient’s share may still change.

Payer Rows

Icon	Payment status	What it means
Gray clock	Pending	The payer has not decided yet, or nothing from that payer has been posted.
Red ✕	Denied	The payer allowed nothing.
Blue arrow	Forwarded to the next payer	The payer paid nothing and passed the balance on, for example when the whole charge applied to the deductible.
Green half-filled circle	Paid, Balance Remaining	The payer paid, but part of the charge is still with this payer: not paid, adjusted, or passed on. The row’s Balance is the amount left.
Green check	Paid, No Balance	The payer paid, and the rest was adjusted or passed on. Nothing is left with this payer.
Gray invoice	Adjusted Off	The payer paid nothing and passed nothing on, and the charge was adjusted.

The Patient Row

Icon	Payment status	What it means
Gray clock	Pending	Insurance is still working the claim, or a payer still holds part of the balance, so nothing is the patient’s yet.
Gray clock	PR Processing	Insurance is finished, but the patient’s responsibility has not been generated yet.
Red exclamation mark	Payment Due	The patient’s responsibility has been generated, and the patient has not paid any of it.
Green half-filled circle	Paid, Balance Remaining	The patient has paid part of their responsibility and still owes the rest.
Green check	Paid, No Balance	The patient has paid their responsibility in full.
Gray invoice	Written Off	The patient’s whole responsibility was written off.

When the Patient row is Pending or PR Processing and something is blocking the patient’s responsibility from being generated, an ⓘ icon appears beside Patient. Hover the icon for the reason, such as a workers’ comp claim, a claim that isn’t balanced, or a balance still with a payer.

Procedure Rows

A procedure’s payment status sums up every payer and the patient on that line. Read the status together with the line’s PR and Balance.

Icon	Payment status	What it means
Gray clock	Pending	Nothing has been paid or adjusted on this line yet.
Blue arrow	Pending Secondary	Insurance adjusted this line but paid nothing, and the line isn’t settled yet. Usually the balance is waiting on the next payer.
Green half-filled circle	Paid, Balance Remaining	Something has been paid and a balance remains. This status covers two different situations, described below the table.
Gray clock	PR Processing	Insurance is finished and a balance remains, but no patient responsibility has been generated for this line yet.
Red exclamation mark	Payment Due	Insurance is finished, everything left on the line is the patient’s, and the patient has not paid any of it, so the Balance matches the PR. On a self-pay claim, any unpaid line shows Payment Due.
Green check	Paid, No Balance	Nothing is owed on this line.
Gray invoice	Adjusted Off	Nothing was paid, and the line was adjusted down to zero.

On a procedure, Paid, Balance Remaining means one of two things. The PR column tells you which:

The PR has an ⓘ icon or is blank: insurance isn’t finished with the line. Part of the balance is still with insurance, or an expected payer hasn’t posted yet, so the patient’s share is provisional. The Balance is usually more than the PR, and the difference is what insurance still holds.
The PR has no ⓘ icon: the patient has paid part of their share. The Balance is less than the PR, and it is what the patient still owes.

✨Smart Tip: A green half-filled circle means partly paid, not all clear. A line showing Paid, Balance Remaining with a provisional PR can need more work than a red Payment Due line: the red line is ready for the patient to pay, while the green line still has money sitting with insurance. Expand a procedure’s row to see every payment and adjustment on that procedure.

Procedures under Unsubmitted Procedures, Procedures Not On Latest Claim, and the two Procedures Deleted groups show a gray Not Submitted, Removed from Claim, or Excluded from Claim icon instead of a payment status.

FAQ

What makes a claim workable?

Three things at once: the claim is your site’s responsibility, its Status is one of the workable ones in the table above, and it is not deferred. The built-in Workable Claims view applies exactly those three conditions, so everything in that view is something you can act on now. See Organizing Your Claims Worklist.

A claim's status says Full Denials but its stage says Payer 2 — which payer denied it?

Payer 2. Status tells you what happened to the claim; Stage tells you who holds the balance now. Hover the Stage to see the payer status for each payer on the claim, and work the one showing Denied.

What is the difference between Partial Denials and Unresolved Balances?

Partial Denials means the payer denied at least one line and paid others. Unresolved Balances means the payer allowed and paid every line and a balance is still sitting on the claim — nothing was denied, so the leftover is either unexplained or was never transferred to the next payer or the patient.

What is the difference between Status and Status Reason?

Status is what needs to happen next. Status Reason is why the claim is there: the denial, rejection, or error code, a plain-language description, the dollar amount, and a per-procedure breakdown. Read the status to triage a claim and the status reason to fix it. See Working a Claim.

Why does a claim show Decision Inconclusive instead of a denial?

Because the payer responded but the response does not settle the claim. This happens with a duplicate-claim denial, a claim the payer forwarded to another payer, a placeholder denial carrying no usable reason code, or a claim whose remittances have all been archived. The claim needs a real decision before it can move on.

​At a Glance

​Status

​Stage

​Payer Status

​Before the Claim Goes Out

​After the Claim Goes Out

​After Money Posts

​Payment Status

​Payer Rows

​The Patient Row

​Procedure Rows

​FAQ

At a Glance

Status

Stage

Payer Status

Before the Claim Goes Out

After the Claim Goes Out

After Money Posts

Payment Status

Payer Rows

The Patient Row

Procedure Rows

FAQ