A claim has been outstanding for 90 days with no payment or denial. How would you investigate it?

When a claim has been outstanding for 90 days with no payment or denial, the first step is to determine whether the claim was actually received and accepted by the payer.

I would review the claim submission history, clearinghouse reports, payer acknowledgments, and any available electronic claim status information. If the claim was rejected or never accepted, the issue should be corrected and the claim resubmitted promptly.

If the claim was accepted, I would then check the payer’s current claim status. Depending on the available tools, this may be done through the payer portal, electronic claim status inquiry, clearinghouse, or payer call.

The goal is to identify whether the claim is:

• Still processing
• Suspended for review
• Pending additional information
• Missing medical records
• Held for coordination of benefits
• Delayed because of provider enrollment or credentialing
• Sent to the wrong payer or plan
• Processed under another claim number
• Not located by the payer despite submission evidence

I would also review the patient’s eligibility and insurance information for the date of service to make sure the correct payer was billed and that the coverage information was accurate.

Next, I would review any previous AR notes. This helps determine whether the claim has already been followed up on and whether the payer previously requested any action.

If the payer indicates the claim is still processing, I would compare the status with the payer’s normal processing timeframe. A claim that has exceeded the expected timeframe may require escalation, reprocessing, or additional follow-up.

If the payer cannot locate the claim but submission evidence exists, I would verify the payer ID, submission route, and acceptance report before deciding whether resubmission is appropriate. Blindly resubmitting can sometimes create duplicate claims.

If the payer requests documentation or correction, I would complete that action and document the follow-up clearly.

The final step is to set the correct next follow-up date and record all relevant details, including the payer representative or reference number when available, claim status, required action, and expected resolution timeframe.

A claim has been outstanding for 92 days.

The AR representative reviews the clearinghouse report and confirms that the payer accepted the claim. The payer portal shows the claim is pending because medical records are required.

The AR representative checks the account notes and finds that the medical records request was never worked.

The records are then submitted through the payer’s required channel, the submission confirmation is documented, and the account is scheduled for follow-up after the payer’s stated review timeframe.

In this case, the delay was not a denial. It was an unresolved pending-information issue.