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Claim Processing Terms

Across
claim that has been received but has not yet been assigned a claim classification
claim denied for the purpose of obtaining additional information from the provider
A Clean Claim that has been denied for payment
claim that has been previously Adjudicated as a Clean Claim and has had a subsequent payment update
claim submitted that does not contain the data necessary to Adjudicate and process the claim.
Down
Clean Claim for which a payment has been made to the provider
claim submitted by the provider that was included in a previously submitted claim by that provider for the same service provided to the same Member
claim pended for the purpose of obtaining additional information from the provider
Claim that has been previously Adjudicated as a Clean Claim and the provider sends written notification that they disagree
Claim submitted by a Provider for rendered services for which the Provider has been prepaid
Claim CMCHP can not process for various reasons