Transaction Processing Overview

Overview

Inpatient, Outpatient and Veteran Medical Claims cannot be processed in real time. They are typically submitted for processing with Medicare, with results being retrieved automatically on the day they have been processed.

Patient Claim Interactive, Same Day Deletes, Online Eligibility Checks, and Patient Verifications are processed immediately, so the following does not apply to them.

Typical processing steps

1. Pending - A transaction has been submitted to MediatR but has not yet
2. Verifying - The patient details in the transaction had been submitted to Medicare prior to the transaction itself
3. Queued - The verification has been successful, and the transaction is in the queue to be submitted.
4. Submitted - The transaction has been submitted to Medicare for overnight processing. This typically happens after 10PM.
5. Processing Report - The submission was successful and includes both response codes and details of fees that will be paid.
6. Payment Report - This details the payment made, and includes account details and a list of related transactions.

Failure status

Not everything will go to plan, so there are the following additional statuses:

1. Failed Verification - One or more of the patients failed verification with Medicare and/or private health insurers. The claim can still be submitted if the relevant claims are removed. See the article; Removing Transaction Claim Entries or Cancelling Transactions to remove incorrect claim entries to allow the claim to continue processing.
2. Timed Out - The claim could not be submitted to Medicare within the, typically 3 day window. The claim will have to be re-submitted for processing.
3. Canceled - If all the claim entries within a transaction are removed before submission or the transaction has been explicitly cancelled. this is the status which will apply.