MANAGING PROBLEM CLAIMS Flashcards
claims that have been refused due to technical errors or
patient coverage errors
already processed & sent to the payer
Denied claims
How can denied claims be resolved at times?
Appealing the decision
this type of claim requires follow up to determine the appropriate action
Delinquent claims
How many days does delinquent claims typically refer to?
30-45 days old
this type of claims have not been processed by the Payer –
only by Clearinghouse / or office system
Rejected claims
reasons for claim rejections…
- Incorrect, invalid, or unspecific
- dx codes
- procedure code
- Incorrect or missing modifier
- Mismatched POS to type of service
- Missing provider or org NPI #
an effective method for claims payment only when the payer indicates no claim on file
Resubmitting (rebilling) claims
it’s a type of claim where the payer indicates no claim on file which could be sent to the wrong payer, and for paper claims includes claims lost in the mail
Lost claims
allows you to address the reason for denial and determine how to correct the claim
Review claim rejections and denials
process used for minor changes to a previously filed claim
Clerical Error Reopening (CER)
What corrections can be made using CER?
▪ Modifiers
▪ Place of services codes
▪ Adding or changing dx codes
▪ Correcting the date of service (if within the same
year)
▪ Most procedure codes
a request submitted to a third-party payer to reconsider a claim that has been paid incorrectly or denied
Appeal
Can appeals be used for rejected claims?
Nope!
What are the 2 reqs of appeal that the coding & billing specialist must be familiar with?
- Having knowledge of the claim details
- Being prepared to provide relevant details that support the claims
this is important for future follow-up
Careful documentation of appeals
What are the five-level appeal process of Medicare?
• Level 1 – Redetermine
• Level 2 – Reconsider
• Level 3 – Disposition
• Level 4 – Review
• Level 5 - Judicial
- filed with the Medicare Administrative Contractor (MAC)
- can be online or in writing
- must be within izo of the initial
claims determination
Redetermination
- filed with the qualified independent contractor (QIC)
- in writing
- must be within 180 of the notice of redetermination
Reconsideration
- filed with HHS OMHA
- by telephone or video teleconference, some cases, can be in-person
- must be within 60 days of the
reconsideration decision
Disposition
by Office of Medicare Hearings and Appeals (OMHA)
- filed with the coundil in writing
- must be within 60 calendar days of the OMHA decision
Review
by the Medicare Appeals Council (Council)
- filed in a district court according to the details provided by the council’s response
- must be within 60 days of the
Council’s decision
Judicial
review in U.S. district Court
What form must request for redetermination of Medicare claims use for submission?
CMS-20027 (Medicare Redetermination Request Form)
indicates the viability of an organization’s revenue cycle, much like a report card for a student
accounts receivable by age reports
arranges billed amounts by the length of time that has gone by without payment
Aging report
A healthy aging report should have the largest amount of
balances owed under what date ranges?
1-30 days
it is the investigative part of the revenue cycle process
Accounts receivable management
Where you should referred to when determining patient responsibility or if the reimbursement is considered as payment in full?
fee schedule and the ERA (Electronic Remittance Advice) /EOB (Explanation of Benefits)
Where should we refer to when determining patient responsibility or if the reimbursement is considered as payment in full?
fee schedule and the ERA (Electronic Remittance Advice) /EOB (Explanation of Benefits)
What is a payer mixer?
how many patients of each payer the organization provides care to
it’s when cannot collect monies or the patient have not paid over a long period of time
Bad debt
