CLAIMS PAYMENTS & FINANCIAL RESPONSIBILITY Flashcards
What is the next step after the claim has been through adjudication?
receipt of payment and the ERA (Electronic Remittance Advice/EOB (Explanation of Benefits) (835 transaction format) for the claim(s)
What should one do if the payer denies the claim or explains that the services rendered are not covered expenses under the patient’s plan?
follow-up with the payer before applying patient financial responsibility
REMEMBER : review all options with the payer before billing the patient
typically indicate the status of the claim for purposes of coordinating benefits
ERA/EOB
What is it called when Medicare will automatically forward a
claim to the secondary payer, relieving the organization of the need to generate a secondary claim?
crossover claim
these standardized codes are used to describe how a claim
was adjudicated and paid
reason codes
used to explain an adjustment
amount, such as a denial, a decrease, or an increase in
payment amount
Three sets of codes
What are the 3 sets f code?
o Claim Adjustment Group Code (Group Code)
o Claim Adjustment Reason Code (CARC)
o Remittance Advice Remark Code (RARC)
used with a group code to form
a response to an adjusted amount, such as denial, a decrease, or an increase in payment amount
two-digit reason codes
3 categories of group codes…
- Contractual Obligations (CO)
- Patient Responsibility (PR)
- Other Adjustments (OA)
How many two-digit codes used w group codes are there?
approximately 400
it’s when the provider charges more than the allowed amount
for a given payer, the coverage is written off
contractual adjustment
this is also dependent on the reimbursement method
Payment time
it is a computer-based transfer of money
can be received in as
little as 7 days from the claims transmission
Electronic Funds Transfer (EFT)
When third-party discovers an overpayment, they can include an____ for it on a future ERA/EOB
adjustment
the final step of the revenue cycle process
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