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Payment Adjudication


what happens after the claim is submitted? the third-party payer or health insurer, is reviewing the claim
accounts receivable department department that keeps track of what third party payers the provider is waiting to hear from & what pts are due to make a payment
what is the primary purpose of CDM? to make sure the provider accurately charges the pt for routine services & supplies
aging report measures the outstanding balances in each account
how are aging reports maintained? in 30 day increments
why are aging reports useful? they help the office staff see which accounts have not been paid
Remittance Advice report sent from the 3rd party payers to the provider
where is the EOB sent? sent to the policyholder
medicare summary notice (MSN) document that outlines the amts billed by the provider & what the pt must pay the provider
what does is mean when physicians accept assignment? the health care professional accepts as payment in full Medicare's allowable charge
what's another name for posting payments? reconciliation & collections
group codes identify the party financially responsible for a specific service or the general category of payment adjustment
claims adjustment reason codes (CARCs) provide financial info about claims decisions
remittance advice remark codes (RARCs) further explain reason for a payment adjustment
provider-level adjustment reason codes are not related to a specific claim. These adjustments are made by the provider's office
affordable care act(ACA) is how pts can appeal health ins decisions
who benefits from the appeals process? the pt
when can a pt request an external independent review? if the claim is still denied
Created by: diasiar