Pended Claims: Why Insurance Claims Pend and How to Resolve Them

TL;DR

• A pended claim has been accepted by the payer but is on hold: no remittance has been issued yet, or only part of the claim has been paid.
• Claims usually pend because the payer is waiting on something: records or other documents from the provider, information from the patient, other-insurance (COB) details, repricing, medical review or an eligibility determination.
• The 277 claim status response tells you which kind of pend you have. P3 means the payer is waiting on information it already requested from the provider, and that is the one you can act on today.
• Send only what the payer asked for, through the channel it names, with its letter attached. Resubmitting the whole claim on a claim form usually makes things worse.
• Timing depends on who governs the claim. Medicare has a 30-day clean-claim payment window and a 45-day standard for claims that need development, and commercial timing depends on state law and your contract.

A claim that sits at "pending" for six weeks is not the same problem as a denial, and it should not be worked like one. A pended claim is one the payer has accepted into its adjudication system but has not finished deciding. X12, the body that maintains the claim status code lists, describes it as a claim "for which no remittance advice has been issued, or only part of the claim has been paid."

The practical question is never "is it pending?" but "what is the payer waiting for, and is it waiting for me?" Some pends clear on their own. Others sit until someone sends a document the payer requested weeks ago. The work is telling those apart quickly.

What "pended" means, and what it does not

A pend is a hold inside adjudication. The claim passed the front-end edits, so it was not rejected, and it has not been finalized as paid or denied. Cigna's explanation of how a medical claim is processed puts it simply: after initial screening, "the claim will either be paid according to your plan coverage, or 'pended' if we need more information from the provider."

That makes a pend different from two statuses it often gets confused with:

• Rejected. The claim never entered adjudication. X12 category A3 means the claim "has been rejected and has not been entered into the adjudication system." You fix and resubmit a rejection.
• Not found. X12 category A4 means the claim "can not be found in the adjudication system." That is the "claim not on file" call, covered below, and it needs a different response than a pend.

If the payer has the claim and is holding it, you have a pend. Our guide to 277 claim status codes walks through the full category system; here the focus is what to do once you know the claim is pended.

Why claims pend: the common holds

X12 splits pending claims into a small set of categories, and status codes add the detail. The table maps the categories to the situations billers usually see.

Within those categories, the status code tells you the specific hold. A few that come up in pend work, all from X12's claim status code list:

• Records and documentation. Code 294 is "Supporting documentation," and related codes name specific items such as 297, "Medical notes/report."
• Coordination of benefits. Code 52 is "Investigating existence of other insurance coverage," and code 171 is "Other insurance coverage information (health, liability, auto, etc.)."
• Repricing. Code 64 is "Re-pricing information," and code 110 is "Claim requires pricing information."
• Eligibility. Code 56 is "Awaiting eligibility determination."

Payer manuals describe the same reasons in plainer language. UnitedHealthcare's 2026 administrative guide says it "may pend or deny a claim and request additional documentation," which "may include itemized bills, medical records or invoices," to determine whether services are covered, medically necessary, free from fraud, waste, abuse or error, and eligible for payment. The same guide describes a less obvious pend: for certain Individual Exchange members in the second and third months of the ACA premium grace period, "UnitedHealthcare pends the claims and sends a letter to the health care provider advising them of the delinquency."

Medical review gets its own treatment in our explainer on what "pending medical review" means. For the other holds, the next step is the same: find out exactly what is being asked, and by whom.

How to find out why a claim pended

Start with the cheapest, most structured source and move to the phone only when it does not answer the question.

1. The 277 claim status response. A 276 inquiry returns a category and status code. For a P3 or P4, X12's usage notes say a status code identifying the type of information requested must be reported, so a well-formed response should name what is missing. Payer usage varies. Cigna's 276/277 companion guide, for example, says that when a claim "has been pended and sent to an Alliance Partner for re-pricing," its 277 returns P3 with status code 64.

2. The payer portal and any letters. Many payers send a formal request. UnitedHealthcare says that when additional information is required, "we will send a formal communication outlining the specific documentation needed to proceed with the review." Check the portal's correspondence or letters area before you call, because that letter is usually what the payer expects you to answer.

3. A call to provider services. Electronic status often stops short of the detail you need. CAQH CORE has said as much: in the 2024 CAQH Index, it noted that providers rely on manual processes partly because they "receive more robust information through these processes" than through the 277, and that its Claim Status Workgroup is focusing on scenarios such as a claim pended for documentation, where the status transaction "should indicate the specific documentation that a provider needs to send to remove the pend rather than a generic response." Until that happens everywhere, a P0 or a vague P3 often means a phone call.

Whatever the channel, record the payer reference or call reference number, the date, who you spoke with and the exact item requested. You will need all of it if the claim later denies for "information not received."

How to resolve a pended claim, by reason

The response depends on who holds the next action.

Records or documents requested from you (P3). Send exactly what was asked, nothing more, through the payer's named channel. UnitedHealthcare advises: "resubmit only what is requested in our communication along with the communication you received," and says not to "use a claim form to resubmit claims that were denied or pended for additional information." Aetna's provider manual says that if it pends a claim for additional information, you can log in to its provider portal, complete a Claim Status Inquiry transaction and "upload your documents through the “Send Attachments” button." It also asks you to include an electronic copy of the EOB or Explanation of Provider Payment.

Information requested from the patient (P4). The payer is waiting on the member, often for an other-insurance questionnaire or accident details. Call the patient, explain what the payer needs and when, and recheck status after they confirm they have responded.

COB questions. If the status points to an other-insurance investigation (code 52 or 171), confirm primary and secondary coverage with the patient and, where it applies, send the primary payer's EOB. Code 286 in X12's list is "Other payer's Explanation of Benefits/payment information," which is often the missing piece in a COB pend.

Repricing or third-party processing (P2). The claim may be with a network or repricing partner. Ask who has it and whether a separate contact applies; Cigna's companion guide says that in some alliance arrangements its 277 includes the partner's name and phone number.

Eligibility determination. Verify coverage for the date of service. If the patient's eligibility is unresolved (code 56, or the grace-period scenario above), the claim generally cannot finalize until the payer resolves it. In the grace-period case, UnitedHealthcare's guide says you may not balance bill the member while those claims are pended.

Payer system or administrative hold (P5) and generic P1. There is usually nothing to send. Recheck on a schedule and escalate if the claim stays in the same status past the window the payer or contract allows.

Cigna's guidance captures the general point: "Most claim issues can be remedied quickly by providing requested information to a claim service center or contacting us." Cigna also separates appeals from "routine requests for follow-up inquiries on claim processing errors or missing claim information." A pend is a follow-up problem, not an appeal, unless the claim later denies, at which point the choice between a corrected claim, a reconsideration and an appeal starts to matter.

How long can a payer keep a claim pended?

There is no single answer, and you should not quote one to a client without knowing which rule governs the claim.

Traditional Medicare. The Medicare Claims Processing Manual says clean claims "must be paid or denied within the applicable number of days from their receipt date," which is 30 calendar days for claims received on or after October 1, 1993. The underlying statute, Social Security Act §1816(c)(2) and §1842(c)(2), frames this as a contract requirement that payment be issued on not less than 95 percent of clean claims within 30 calendar days. There is also a payment floor: HIPAA-compliant electronic claims are not paid before the 14th day after receipt, and paper claims not before the 29th day.

A claim that pends for development is, by definition, not clean. For those "other-than-clean" claims, the manual cites Social Security Act §1869(a)(2) and directs contractors to process them and notify the provider within 45 calendar days of receipt. However, the contractor "shall cease counting the 45 calendar days on the day that the contractor sends the development letter," and resumes counting when the requested materials arrive. Slow responses to a development letter extend the timeline.

Medicare Advantage. Under 42 CFR 422.520, an MA organization must pay 95 percent of clean claims within 30 days of receipt when they are submitted by, or on behalf of, enrollees of MA private fee-for-service plans or are for services not furnished under a written agreement, and must pay or deny all other non-contracted claims within 60 calendar days. For contracted providers, the regulation requires a prompt payment provision in the contract, with terms "developed and agreed to by both the MA organization and the relevant provider." Check your contract, not the 30-day figure.

Commercial plans. State prompt-pay laws differ. The NAIC's Spring 2024 chart of claims settlement provisions (state entries last reviewed April 2024), for example, summarizes Alabama's health claims rule as 45 days for paper and 30 days for electronic claims, and Mississippi's as 25 days for electronic and 35 days for paper clean claims. Both of those entries also set a deadline for notifying the provider when a claim is not clean or needs more information, a detail worth checking in your own state. Our guide to prompt pay laws explains which rule applies when and what starts the clock.

When the payer says the claim is not on file

"Missing claim" and "claim not on file" calls are a separate problem that often gets lumped in with pends. If the 277 returns A4 ("can not be found in the adjudication system") or the representative cannot locate the claim, the payer is not holding it. X12 also uses status code 35, "Claim/encounter not found." A D0 category means the search itself failed: "The payer is unable to return status on the requested claim(s) based on the submitted search criteria," which can mean the inquiry used the wrong member ID, dates or billed amount.

Before resubmitting, rule out a bad search, then confirm through your clearinghouse reports whether the payer acknowledged the claim. If it truly never arrived, resubmit promptly and keep the acceptance report as proof of filing. Every day spent assuming a missing claim is merely pended is a day closer to the payer's filing limit, which our piece on timely filing deadlines covers in detail.

Keeping pends from aging into denials

Pends turn into write-offs when nobody owns the next action. A few habits keep them moving:

• Separate "waiting on us" from "waiting on them." P3 and P4 belong in an active work queue with a due date. P1, P2 and P5 belong in a recheck queue.
• Store the codes, not just the word "pending." A category plus status code tells the next person what to do without a new call.
• Log the request date. For Medicare development letters, the clock stops on the day the letter is sent, so your response date matters.
• Recheck after you respond. A document sent is not a document received. Confirm the pend cleared or moved.

Teams with large pend inventories often spend most of their time just finding out why each claim is held. SuperDial's claim status workflow retrieves status, pending indicators, payer reference numbers and next actions through EDI, payer portals or phone calls and returns them as structured fields, so staff can spend their time on the claims that need a response.

FAQ

Is a pended claim the same as a denied claim?

No. A pended claim is still in adjudication and has not been finalized. A denial (X12 category F2) is a finalized decision. A pend can become a denial if the requested information never arrives, so treat P3 and P4 pends as time-sensitive.

Should I resubmit a pended claim?

Generally no. Resubmitting can create a duplicate. UnitedHealthcare specifically says not to use a claim form to resubmit claims pended for additional information. Send only the requested information through the payer's attachment or correspondence process.

What does "pending, awaiting information from provider" mean on a 277?

That is category P3: the payer is waiting for information it says it has already requested from you. Look for the accompanying status code, the portal letter or the request in your correspondence, and respond with exactly that item.

Why does a Medicare claim show pending for two weeks even when nothing is wrong?

Medicare has a payment floor. A clean, HIPAA-compliant electronic claim is not paid before the 14th day after receipt, and a paper claim not before the 29th day, so a short pending period is normal.

Sources

• X12, Claim Status Category Codes (code list 507): https://x12.org/codes/claim-status-category-codes
• X12, Claim Status Codes (code list 508): https://x12.org/codes/claim-status-codes
• Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, Chapter 1: General Billing Requirements (Rev. 13725, issued April 10, 2026): https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c01.pdf
• Legal Information Institute (Cornell Law School), 42 U.S.C. 1395h, Social Security Act §1816: https://www.law.cornell.edu/uscode/text/42/1395h
• Legal Information Institute (Cornell Law School), 42 U.S.C. 1395u, Social Security Act §1842: https://www.law.cornell.edu/uscode/text/42/1395u
• eCFR, 42 CFR 422.520, Prompt payment by MA organization (current as of October 27, 2026): https://www.ecfr.gov/current/title-42/section-422.520
• UnitedHealthcare, 2026 UnitedHealthcare Care Provider Administrative Guide for Commercial, Individual Exchange and Medicare Advantage: https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf
• Aetna, Provider manual: Resources, policies and procedures at your fingertips (form 8102800-01-01, 6/26): https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/health-care-professionals/office_manual_hcp.pdf
• Cigna Healthcare, How a medical claim is processed (January 8, 2026): https://newsroom.cigna.com/how-a-medical-claim-is-processed
• Cigna Healthcare, Appeals and Disputes: https://www.cigna.com/health-care-providers/coverage-and-claims/appeals-disputes
• Cigna, Companion Guide: Health Care Claim Status Request and Response 276/277, Version 4.0 (October 2025): https://www.cigna.com/static/www-cigna-com/docs/5010-276-277-companion-guide.pdf
• CAQH, 2024 CAQH Index Report: From Transactions to Trust: https://www.caqh.org/hubfs/Index/2024%20Index%20Report/CAQH_IndexReport_2024_FINAL.pdf
• National Association of Insurance Commissioners, Claims Settlement Provisions chart (Spring 2024): https://content.naic.org/sites/default/files/model-law-chart-mc-50-claims-settlement-provisions.pdf