The silent claim: an ABA operating guide to claim-status follow-up

Why ABA claims go quiet

Most ABA billing teams are built around denials. A denial arrives on an 835 with a reason code, lands in a queue, and someone works it. That model has a blind spot: the claim that never produces a remittance at all. No payment, no denial, no adjustment. It does not appear in any denial report because nothing was denied, and it does not appear as a problem in most aging reports because it looks exactly like a claim that is simply waiting.

ABA is unusually exposed to this. A single child generates dozens of claim lines a month across 97153, 97155 and 97156. Technicians and BCBAs change often, so rendering-provider data changes often. Authorizations are tied to specific codes, units and date windows. Many groups bill several states and dozens of plans, each with its own enrollment file. Any mismatch between the claim and the payer's enrollment or authorization record can stop a claim before adjudication, and a claim that is never adjudicated never generates an 835.

In one multi-state ABA engagement, described in our companion case study, claims that had been submitted and never answered made up 60.6% of the open receivable, while denials were a much smaller share. The group's denial process was working. Nobody owned the silence.

The legal clocks on an unanswered claim

Every payer class that pays for ABA operates under some prompt-payment rule. Those rules give a billing team two things: a date after which silence is itself a problem, and leverage when it is raised. The rules differ by payer class, so the first step is to know which clock applies to each claim.

Medicaid fee-for-service is governed by 42 CFR 447.45. The state agency must pay 90 percent of clean claims from practitioners within 30 days of receipt and 99 percent within 90 days, and must require providers to submit claims within 12 months of the date of service. Medicaid managed care organizations are bound to the same 30 and 90 day standards through their state contracts under 42 CFR 447.46, unless the plan and provider agree in the contract to an alternative schedule.

Fully insured commercial plans fall under state prompt-pay statutes. Illinois requires insurers, HMOs, managed care plans and third party administrators to pay within 30 days after receipt of due proof of loss, with interest at 9% a year after that. Texas requires an insurer to decide a clean claim from a preferred provider by the 30th day for an electronic claim and the 45th day for a paper claim. California requires a health care service plan to reimburse a complete claim within 30 calendar days or notify the provider in writing that it is contested or denied. Florida requires a health insurer to pay, deny or contest an electronic claim within 20 days, to pay or deny within 90 days, and treats failure to pay or deny within 120 days as an uncontestable obligation to pay.

Self-funded employer plans are governed by ERISA rather than state insurance law. The Department of Labor claims rule requires the plan administrator to notify the claimant of an adverse decision on a post-service claim within a reasonable period, not later than 30 days after receipt, with one extension of up to 15 days when properly noticed.

How Florida's clock reads on a single electronic claim

Florida's statute is useful as a model because it spells out each stage. The insurer must acknowledge an electronic claim within 24 hours after the start of the next business day, act on it within 20 days, pay or deny it within 90 days, and if it has done neither by day 120 the obligation to pay becomes uncontestable. Other states are less explicit, but the same structure applies: acknowledgment, a decision window, and a point at which silence costs the payer.

The practical lesson is that the provider has to be able to prove receipt. That means keeping the 999 and 277CA acknowledgments for every batch and tying them to individual claims, so that when a claim reaches day 45 with no answer you can show the date the payer received it.

The Medicaid standard in one picture

Medicaid is the dominant payer for many ABA groups, and its standard is a share of claims rather than a hard per-claim deadline. A state agency can comply while a small share of clean claims waits longer than 30 days. That is exactly why individual claims slip: the system is designed to pay most claims quickly, not every claim. A provider who waits for the payer to notice will wait.

Use the standard as your expectation. If more than about one in ten of your clean Medicaid claims are still unanswered at day 30, or any meaningful share at day 90, something on your side or the plan's side is broken, usually enrollment, rendering-provider data, or the authorization link.

A follow-up cadence: day 21, day 35, day 45

The cadence we work to has three touches, timed against the clocks above. It is a worked discipline, done through each payer's own portal or the 276/277 claim-status transaction, not a promise of automation. HIPAA adopted operating rules for the claim status transaction under 45 CFR 162.1403, so every payer that accepts electronic claims should answer a 276 with a 277.

Day 21 is the first status check. By then a clean electronic claim should have been acknowledged and, for most payers, adjudicated. The question is narrow: does the payer have the claim, and in what status? A not-found response here is the cheapest possible catch, because the timely filing window is still wide open.

Day 35 is the escalation check. Most of the 30-day prompt-pay windows have passed. Any claim still pending gets a reason: pended for information, pended for authorization review, or rejected at the front end. Each reason routes to an owner: credentialing for enrollment and rendering problems, the authorization team for auth mismatches, billing for data defects.

Day 45 is the written follow-up. For insured plans in prompt-pay states, a claim still unanswered at day 45 is outside the statute, and the follow-up should say so, cite the acknowledgment date, and ask for a decision. For self-funded plans, cite the ERISA 30-day decision period. For Medicaid managed care, raise it with the plan's provider relations contact and keep the record for the state complaint process if it continues.

• Day 21: confirm receipt and status for every claim with no 835. Resubmit only claims the payer cannot find.
• Day 35: assign a reason and an owner to every pending claim. Enrollment and rendering issues go to credentialing the same day.
• Day 45: written follow-up citing the acknowledgment date and the applicable prompt-pay or claims-procedure rule.
• Every month: measure remittance coverage by payer and review any payer below 90%.

Remittance coverage: the test that finds broken enrollments

The single most useful diagnostic for silent claims is simple to compute and rarely reported. For each payer, take the claim lines billed in a period and count the share that ever produced a remittance line of any kind: paid, denied or adjusted. That share is remittance coverage.

Coverage tells you what kind of problem you have. Below about 30%, the payer is not adjudicating your claims at all, which almost always means an enrollment failure: a group or rendering provider not loaded, an ERA enrollment missing, or claims routed to the wrong payer ID. Between roughly 60% and 80%, part of the book is getting through and part is not, which points to an enrollment and member-registration audit. Above 90%, the payer is adjudicating, and whatever is left unanswered is a claim-status discipline problem.

These thresholds are our working rules from ABA engagements, not a published standard. Their value is that they separate an enrollment problem, which a status call will never fix, from a follow-up problem, which enrollment work will never fix.

ABA-specific causes of silence

When we trace silent ABA claims back to cause, the same handful of defects recur.

• Rendering provider not enrolled or not matched: an RBT or new BCBA billed as rendering before the payer has loaded them, or a name or taxonomy mismatch with NPPES.
• Group NPI and ERA enrollment out of step: remittances for one entity's claims routed to another entity's account or system, so cash arrives but the claim never closes.
• Authorization linkage: claims billed outside the authorized date window, for a code the authorization does not list, or against an authorization number the payer cannot match.
• Payer ID and routing: claims sent to a plan's legacy payer ID after a plan change, administrator change or regional contractor change.
• Front-end rejections never worked: a 277CA rejection is not a denial and will not appear on an 835; if nobody reads rejections, those claims never existed as far as the payer is concerned.

Proving receipt and protecting filing limits

Silence becomes write-off when it outlasts the filing limit. Medicaid requires claims within 12 months of service under the federal rule, and many plans set shorter limits by contract. A claim that was never received by the payer has not been filed, whatever your system says. That is why the day 21 check matters most: it is the only point at which a not-found claim can be resubmitted with time to spare.

Keep, for every claim, the batch acknowledgment and the claim-level acknowledgment, and record the payer's claim number when one is assigned. When you do need to argue timely filing, that record is the proof. Without it, the conversation is about your word against the payer's system.

What to measure each month

Four measures tell a practice owner whether silence is under control. None of them is a denial rate.

• Unanswered claims by age: count and contract value of claim lines with no remittance at 30, 60, 90 and 365 days from submission.
• Remittance coverage by payer, with any payer below 90% named and owned.
• First-pass yield measured honestly: contract value paid in full on the first remittance, with unanswered claims counted as failures, not as clean claims.
• Rejections worked within two business days, as a share of all front-end rejections received.