Claims Status & Results

Understanding Doulado Claim Statuses

When a claim is submitted through Doulado, it goes through multiple stages before reaching the payer for processing. Depending on a claim’s status, you may need to reach out to the payer directly for additional information. To reference a claim with a payer, you usually need to provide them the client’s member ID and the date(s) of service on the claim. 

The "status" and "result" can come from either clearinghouse or payer. Here is what they mean:

• Status: This indicates the status of the submission (Draft -> Submitted -> Processed). The status is is answering: Where in the process is this claim? How far has it gone in the process?
• Result: This indicates the current outcome of the claim based on it's status. For the given status, was there an outcome determined yet? If so, what is it?
  • Draft -> No result yet
  • Submitted -> Accepted or Rejected
  • Processed -> Paid or Denied

Below are the different statuses and results you may see as your claim moves through the clearinghouse to the payer:

Draft

• The claim has been created but has not yet been sent to the clearinghouse.
• Action Needed: Review and submit the claim to proceed.

Submitted

• The claim has been sent from Doulado to the clearinghouse for initial processing.
• No action is needed unless the claim is rejected.

Rejected

• The clearinghouse or the payer has found errors in the claim, preventing it from being accepted into their system for processing. Because of this, a payer may not be able to locate a rejected claim in their system. Check out this article on common rejections and solutions.
• Action Needed: Review the rejection reasons, bring the claim back into draft mode with the revise button, correct any issues, and resubmit the claim.

Accepted

• The claim status is accepted when the claim has been accepted either by the clearinghouse or by the payer into the adjudication process (a process in which an insurance company decides whether to approve or reject a claim). Accepted is usually the last status update you will see in Doulado if you have not set up ERAs. Any further communication from the payer about payment or rejection will be communicated directly to you however you normally hear from that payer.
• No action is needed unless further documentation is requested.

Denied

• The payer has reviewed the claim and determined it cannot be paid due to specific reasons.
• Action Needed: Review the denial reason, correct errors if applicable, and resubmit or appeal if necessary.

Paid

• The payer has processed, and paid the claim. The payer could make a full or partial payment of the claim amount. If you do not have ERAs set up, you can manually enter the payment information to keep track in Doulado. See this article for more instructions.
• No further action is needed unless there are discrepancies in the payment. Review the Explanation of Benefits (EOB) for details. You may need to bill the client or appeal for additional reimbursement.

By monitoring these statuses within Doulado, you can ensure your claims are processed efficiently and address any issues promptly. We recommend setting a schedule and checking in on your claim statuses weekly or bi-weekly. If you have questions about a specific claim, and have already tried reaching out to the payer with no success, please reach out to support@doulado.co to see if we can assist in any way.