Claims 101
What is a Claim?
A medical bill Headway sends to the insurance carrier to determine payment and client responsibility.
Where do you find claim data for a specific session?
Inside the session → Claims tab
When should you make a Claims IA call?
When two identical claims processed differently — use one as leverage.
Define reprocessing
The payer re-evaluates a claim that’s already been processed
What should you confirm when an INN claim seems underpaid?
Questions around CPT codes, place of service, and provider license type
What triggers a claim to be created in Headway’s system?
The provider confirming the session in Atlas.
What does “Claim Submission Status = blank” mean?
The claim was never sent to the payer.
What is the purpose of a Claims call?
To clarify or fix processing inconsistencies after the claim has already been submitted
Define resubmission
Headway re-sends a corrected or updated claim (often after denial)
A rep refuses to reprocess a claim—what do you do next?
Ask why, document the reason, and inform the CCA in your response
What does the acronym EOB stand for, and who receives it?
Explanation of Benefits, received by the client.
What does the “Patient Charged Status” show?
The outcome (Paid, Denied, or Adjusted)
What is a bad reason to make a Claims call?
When the claim hasn’t been submitted or is still processing (<30 days)
What should you always ask for when the payer agrees to reprocess a claim?
A reprocessing reference number
What’s the best probing question if a claim was denied for missing information?
Can you tell me which info was missing and if it can be corrected via resubmission or reprocessing?
What’s the difference between an ERA and an EOB?
ERA = what Headway receives (electronic version)
EOB = what the client receives. Both explain how the claim processed.
What tool gives you the fastest clues when investigating a claim issue?
The Claims Dashboard or JSON view
Before escalating a claim, what key details must you verify first?
Confirm that the session was confirmed in Atlas, the claim was submitted and processed, and that you’ve reviewed the JSON or ERA to rule out portal or data errors
What are the three main claim outcomes?
In-network (INN), Out-of-network (OON), or Denied
What should you do if the rep forgets to give a call reference number?
Politely ask for it before ending the call
Name two things a claim tells the insurance company.
Example answers: date of service, CPT code, provider info, or billed amount.
What does “Adjusted” mean in the Claims Dashboard?
The payer processed the claim and made changes (partial payout or modification)
What’s the difference between a Claims IA call and escalating to Claims Ops?
A Claims IA call is made to the payer to clarify or correct a processed claim, often leading to reprocessing.
A Claims Ops escalation happens after the call when Headway needs to resubmit or correct the claim internally.
What’s the difference between reprocessing and resubmission?
Reprocessing: done by payer after correction Resubmission: done by Headway internally after updating info
Name two great probing questions to ask during a claims call
1️⃣ “What’s the specific payer ID for behavioral health claims?"
2️⃣ “Can you confirm Headway is in-network and should submit directly to that payer ID?”
3️⃣ “What are the timely filing requirements for this plan?”