What is a Pending Insurance Claim?

Dealing with insurance claims can be confusing, especially when you see your claim has a “pending” status. This article explains what a pending claim means and the reasons insurers use this designation before approving or denying a claim.

What Does “Pending” Mean for an Insurance Claim?

When an insurance claim is marked as “pending”, it means the insurance company is holding the claim temporarily instead of processing and paying it right away. Essentially, pending puts the claim on hold.

The insurer needs to investigate the claim further or wait for additional information before deciding to approve or deny it. Claims will stay in pending status until the insurer finishes reviewing.

Why Insurers Pend Claims

There are several common reasons an insurance company may hold a claim as pending:

• Need more information – The insurer requires additional documentation from the policyholder or healthcare provider to verify eligibility and medical necessity. Common examples are medical records, itemized bills, or accident details.

• Appears suspicious – Something about the claim raises red flags for potential fraud or abuse, prompting further investigation.

• Processing backlog – Claims volume exceeds the insurer’s normal workload capacity, causing delays. Pended claims are essentially put on the back burner.

• Pre-payment checks – Validation steps like coordination of benefits must be completed before finalizing payment on a large claim.

• Disputes payment – The insurer disagrees with the billed charges or questions certain services based on policy coverage terms.

• Awaiting premium payment – Policyholder is behind on monthly premiums, so claims are held until payment is made to restore active coverage.

In all cases, the pending status allows insurers time to resolve outstanding issues and feel confident about the validity and accuracy of the claim before paying it.

The Pending Process Step-By-Step

A general outline of the claims process leading to pending status is:

1. Claim submission – Policyholder or provider sends claim to insurer after receiving medical services.

2. Initial review – Insurer validity checks for member eligibility, provider network status, coverage alignment, and claim completeness.

3. Pended for review – If issues are found or information is missing, the claim is marked as pending for further review.

4. Investigation – Insurer requests additional data from policyholder or provider and closely analyzes claim details.

5. Resolution – After issues are addressed, the claim can exit pending status and be finalized and paid.

6. Policyholder notified – Explanation of benefits (EOB) is sent detailing status, payments, adjustments etc.

The timeframe varies by several factors, but most pended claims reach a final resolution within 30-90 days depending on complexity.

Will Pended Claims Eventually Be Paid?

The good news is pending status does not automatically mean a claim is denied. Many pended claims do end up getting paid in full or in part after the review is finished.

However, if major problems are uncovered or disputes cannot be resolved, the insurer may end up denying a previously pended claim. Outcomes depend on each specific situation.

According to industry data, over 75% of pended claims are ultimately paid, with the rest partially adjusted or denied after pending, highlighting that the designation does not guarantee a negative outcome.

Policyholder Next Steps for Pending Claims

If you receive an EOB or claim status update showing a pending designation, here are some steps to take:

• Review the reason – Understanding why it is pended allows you to address any open issues.

• Provide requested information – Promptly send any additional data the insurer requires to help finalize the claim.

• Follow up on delays – Check back if a pending claim is stuck in limbo too long without resolution.

• Be patient – Allow reasonable time for processing but persistently follow up if needed.

• Dispute any denial – If the outcome is unsatisfactory, submit an appeal providing rationale for reconsideration.

• Pay premiums – Keep policy active and out of default, which causes all claims to pend.

Staying engaged in the process will help ensure your pending claim has the best chance of getting approved and paid.

Five Common Reasons Insurers Pend Claims

While many factors can trigger pending status, these are among the most prevalent:

1. Coordination of Benefits (COB) – Confirming if another insurer is primary payer before finalizing amount due.

2. Eligibility – Verifying the member was actively covered on the date of medical services.

3. Medical necessity – Justifying treatments were medically needed and appropriate for the diagnosis.

4. Provider network – Determining if the doctor/facility was in-network or if out-of-network terms apply.

5. Pre-approvals – Checking if required prior authorizations were obtained from the insurer where needed.

Asking the insurer for claim denial reasons can help you to understand the most common factors applicable to your own pending claims.

Consequences of Pended Claims for Providers

From the provider perspective, pended claims also create challenges:

• Cash flow disruptions when payments are delayed for lengthy investigations.

• Increased administrative work to supply documentation needed to resolve pending claims.

• Potential bad debt if claims are ultimately denied after originally pended.

• Difficulty setting patient expectations when claims are stuck pending for unknown reasons.

Despite headaches for providers, prudently pending questionable claims reduces insurer losses from improper payments.

Is There a Time Limit for Pending Claims?

There are no strict legal limits on how long insurers can keep a claim in pending status. However, most states require insurers to make a determination within 30-60 days at most for clean claims containing all information.

Complex claims or those with voluminous medical records may take 90-180 days to come off pending status in extreme cases. If an unreasonable delay occurs, policyholders can file complaints with the state insurance department.

Key Takeaways

• Pending claims are essentially in a temporary hold status while insurers investigate further.

• Claims can be pended for many reasons, usually due to missing data or questionable charges.

• Most pended claims do end up getting paid after the pending issues are resolved.

• Policyholders should be patient but stay engaged to help finalize pended claims.

• Insurers pend claims to control improper payment risks but aim to resolve them quickly.

Understanding pended claims reduces frustrations and facilitates faster resolutions so that policyholders can receive reimbursement for covered medical expenses.

Frequently Asked Questions (FAQ)

How long can an insurer legally pend a claim?

There is no defined legal limit, but most states require insurers to finalize pended claims within 30 to 60 days for routine cases. More complex claims may take 90 days or longer to come off pending status.

Will I eventually get paid on my pending claim?

Many pended claims do end up getting paid, but some are partially adjusted or denied after review. Outcomes depend on the specific circumstances of each claim.

Does pending a claim mean it will be denied?

No, pending status does not guarantee a claim denial. Insurers often pend claims just to buy more time to fully validate all charges and details before approving payment.

What happens if I never provide the information requested for a pended claim?

The claim will likely remain stuck in pending limbo indefinitely without the requested documentation. Failure to respond typically results in the insurer ultimately denying the claim.

Is there anything I can do to prevent my claims from getting pended?

Proactively confirming coverage terms, securing pre-approvals, utilizing in-network providers, and fully completing claim forms can reduce chances of ending up with pended claims.

If my policy lapses, will my pending claims still be paid?

Unfortunately, no. If your coverage terminates for non-payment before pending claims are finalized, they will be denied rather than approved and paid.

Are doctors negatively impacted by pended claims?

Yes, delayed reimbursement and potential claim denials down the road can disrupt provider cash flow and revenue. Pended claims also create administrative work for providers to supply documentation needed.

Can I call my insurer to get a pending claim paid faster?

You can try calling the claims department for an update but rarely will this accelerate pending claims. Supplying requested data and giving reasonable time for review is still the main avenue for resolution.

What recourse do I have if I feel the insurer is unfairly pending my claims?

You can file complaints and appeals, supply evidence the services met policy terms, and contact your state insurance regulator if you believe the insurer is acting in bad faith or violating claim processing requirements.