Reference 0010
Claim Outcome Triage Card
A quick reference for separating batch rejection, claim rejection, denial, remittance adjustment, and claim status signals.
Use this whenever a workflow says only "claim failed." That phrase is not precise enough for product design.
Outcome Codes
| Code | Signal | Next Action |
|---|---|---|
| BCH | Entire batch or file rejected before individual claim processing. | Fix transmission or batch format and resend. |
| RJT | Individual claim rejected for correction and resubmission. | Fix claim data, preserve rejection reason, and resubmit. |
| DNY | Claim denied by payer coverage or payment decision. | Work denial, appeal, correct claim, or route for write-off review. |
| ADJ | ERA or SPR reports final adjudication, payment, responsibility, or adjustment data. | Post payments, adjustments, patient responsibility, or provider-level adjustments. |
| STS | 276/277 status exchange reports where the claim is in process. | Update tracking, reminders, and workqueue timing. |
Design Invariant
Never store only claim_failed. Store the stage, source, correction action, financial effect, and whether resubmission is expected.
Fast Triage
| Question | If Yes |
|---|---|
| Did the whole file fail before claim-level processing? | BCH |
| Can staff correct the claim and resubmit before final adjudication? | RJT |
| Did the payer make a coverage or payment decision against the claim? | DNY |
| Does the signal include money, responsibility, CARC, RARC, or group code data? | ADJ |
| Does the signal only report current claim processing status? | STS |
Source Anchors
- CMS Electronic Health Care Claims distinguishes batch rejection, individual claim rejection, and denial outcomes across claim edit levels.
- CMS Health Care Payment and Remittance Advice describes ERA and SPR as final claim adjudication and payment information with adjustment reasons and values.
- CMS Claim Status Request and Response describes 276 requests and 277 responses for obtaining and posting claim status information.