Claim Processing and Reporting Workflow

After submitting a claim, follow this workflow to process and report your claim.

Reports and Responses — for API customers

The filenames begin with a two-character prefix mentioned with each response description below, followed by the associated submitter ID. The filenames end with a two-character extension that begin with AA, AB, AC…. A0, A1, A2…BA, BB, BC…. ending with W9 before rolling back to AA (excluding AU, BK, DB, DV, GI, GW, HT, JS, QT, RA, RP, and WM).

Recommended workflow

Clearinghouse response

1. CF – Claims Summary Data File — clearinghouse rejections, balancing, claim routing.

2. UF – Claims Summary Data File (Recreates) — recreates submitted by clearinghouse, exceptions only.

3. FX - Notification Report — notification of the file transmission delay to payer, exception basis. Indicates the problem claims removed from batch file and rejection reason.

   a. Provided by our Audit team to communicate issues with claims when we are notified of issues through non-traditional means (that is, 999 or 277 payer response files).

Payer response

1. CN – Notification Report — paper claims returned by the payer.
   a. The CN is used to provide notification of a paper claim that could not be delivered to the intended address; primarily, for paper carrier-direct claims that contain an invalid address, and are returned to clearinghouse as undeliverable.
2. SF – Payer Report Data File (Normalized) — claim level payer rejections OR X3 – 277 Payer Claim Status
   a. The X3 file returns the x12 raw data that matches exactly what is returned by the payer and can be translated into JSON.
   b. The SF file is a proprietary pipe delimited file that returns the same information as the X3 file except it also returns an Enhanced Claim Status Code. The Enhanced Claim Status Code is determined by programming logic in our system that translates the Claim Status Category Code into the enhanced code and adds to the SF file.
   c. The claim status code itself implies if the claim was accepted, rejected, pended, and so on. If you would like to receive the Enhanced Claim Status Code instead, complete mapping for the SF file instead of the X3.
3. SD – Payer Batch Totals Data File (Normalized) — batch level payer rejections, returned for payers that return provider level information.
   a. The SD file is a payer batch response file that is not included in the SF or X3 files.
   b. Example: Medicare is rejecting all of the provider’s claims at the payer batch level due to the individual provider being sent for the billing provider on the claims. The individual providers are not enrolled for claim submission. This rejection is only returned in the SD file.
   c. R5 – Remittance Transaction Set – 835 — payment and denial information from the payer.
   d. Can be viewed in ANSI X12 EDI or translated into JSON.