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A lost claim is revenue you already earned and still cannot collect. It left the clinic as a service delivered, but somewhere between submission and settlement it disappeared into a follow-up queue that no one owns. Sigma treats each claim as a tracked work item with a clear status, a visible history, and — when something goes wrong — an actionable next step. Nothing sits in a mystery queue.

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Claim Lifecycle

1

Prepare

Build the claim directly from the confirmed patient invoice. Sigma pulls the visit details, line items, scheme codes, and the scheme portion automatically. There is no separate spreadsheet to populate — the invoice is the source of truth.
2

Validate

Before the claim leaves the system, Sigma checks for authorisation numbers, scheme codes, diagnosis codes, and mismatched fields. Errors surface at this step so your team can correct them before submission — not after the insurer rejects the claim.
3

Submit

Send the claim to the insurer. Sigma stores the exact submitted version, including the submission timestamp, so you always have a record of what was sent and when. No more “we never received it” without a documented response.
4

Track

The claim moves through a defined sequence of statuses from Submitted through to Paid. You can see where every claim stands at any point, without calling the insurer to ask.
5

Follow Up

Rejected claims surface automatically as actionable items in the claim queue. Sigma displays the rejection reason from the insurer, so your team can identify the issue, make the correction, and resubmit — all within the same workflow.

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Claim Statuses

Every claim in Sigma carries one of the following statuses at all times. The status tells you exactly what action, if any, is needed next.
  • Submitted — The claim has been sent to the insurer and is awaiting a response. No action is required yet.
  • Awaiting Response — The claim has been with the insurer for longer than the expected response window. Follow-up contact may be warranted.
  • Approved — The insurer has approved the claim. Payment is expected according to their payment cycle.
  • Rejected — The insurer has rejected the claim. Open the claim to view the rejection reason and correct before resubmitting.
  • Paid — The insurer’s payment has been received and matched to this claim in the Payments module. The scheme balance is closed.
  • Waiting — The claim is being held internally before submission — typically because a required field such as an authorisation number is still outstanding.

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Common Rejection Reasons

Most insurance schemes require a pre-authorisation number for procedures above a certain cost threshold or in specific clinical categories. If the authorisation number was not captured at the time of the visit, the claim will be rejected. Add the authorisation number to the invoice, update the claim, and resubmit. To prevent this in future, confirm the authorisation number before the procedure is performed and record it on the encounter.
Each insurer uses a defined list of scheme or benefit codes to route claims to the correct plan. A code that does not match the patient’s active plan — or a code that has been retired — will trigger a rejection. Verify the patient’s current scheme membership and correct the code before resubmitting.
Some schemes require that the diagnosis codes on the claim align with the procedures billed. A surgical procedure submitted with a diagnosis code that does not clinically justify it will be rejected. Review the diagnosis codes on the encounter and ensure they match the services delivered.
Insurers enforce filing deadlines — typically 90 to 180 days from the date of service, depending on the scheme. Claims submitted after the filing window closes will be rejected and cannot be resubmitted. Submit claims promptly after each confirmed invoice to avoid this category of loss entirely.
If a patient’s scheme membership had lapsed, was suspended, or had not yet commenced on the date of service, the insurer will reject the claim. Verify active membership at the time of patient registration and flag any eligibility uncertainty before providing scheme-covered services.

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Claim Queue

The claims view in Sigma is a work list, not a search results page. Every claim displayed is an open item that needs attention — whether that means waiting for an insurer response, correcting a rejection, or confirming that a payment has been matched. Closed and paid claims are archived and remain accessible for audit, but they do not clutter the active queue. Filter the queue by status, insurer scheme, submission date, or responsible staff member to prioritise the work that matters most on any given day. A claim that has been sitting in Awaiting Response for two weeks is a different priority than one submitted yesterday.
The claim is the clinic’s record of what left the building — and what still needs a person. A claim in the queue is not an administrative task; it represents real revenue that has not yet been collected. Treat each open item as an outstanding receivable, because that is exactly what it is.

Billing

Build accurate invoices that produce clean claims the first time.

Payments

Match insurer remittances to claims once they are approved and paid.

Claim Submission

Step-by-step walkthrough of preparing, validating, and submitting a claim.

Revenue Tracking

Monitor claim outcomes and outstanding receivables across schemes.