VIGNESH JAGANRAJ

• The Initial Processing Review
• The Automatic Review
• The Manual Review
• The Payment Determination
• The Payment

The Initial Processing Review :
In the initial processing review, claims are checked for simple claim errors or omissions.Problems identified during the initial processing review include:

.The wrong patient name or incorrect spelling
.The subscriber identification number or plan number is wrong
.The place of service code is wrong
.The date of service is wrong
.The diagnosis code is missing or invalid
.The patient's gender does not match the type of service

When a claim is rejected for any of the above reasons, it can simply be corrected and resubmitted for payment.

The Automatic Review :
In the automatic review, claims are checked for more detailed items that apply to the insurance payers payment policies.Problems identified during the automatic review include:

.The patient is not eligible on the date of service.

.This could mean the coverage has termed or is not active.
.The claim submitted is a duplicate claim: This could mean that a claim has already been submitted for the same date or procedure.
The Manual Review :
In the manual review, claims are checked by medical claim examiners. It is not uncommon for nurses or physicians to also manually review these claims during this process. Medical records may be requested to compare the claim with the medical documentation. This can be conducted for any type of procedure but most commonly with an unlisted procedure to determine medical necessity.

The Payment Determination :
There are three types of payment determinations:

Paid: When the claim is considered paid, the payer determines that the claim is reimbursable
Denied: When the claim is considered denied, the payer determines that the claim is not reimbursable
Reduced: When it is determined that the service level billed is too high based on the diagnosis, the procedure code can be downcoded to a lower level deemed appropriate by the claims examiner.

The Payment
The payment submitted to the medical office supplied by the insurance payer is called a remittance advice or explanation of payment. It details the notice of and explanation reasons for payment, reduction of payment, adjustment, denial and/or uncovered charges of a medical claim.
The remittance advice typically includes the following information:
.Payer Paid Amount,Approved Amount
.Allowed Amount,Patient Responsibility Amount
.Covered Amount,Discount Amount.

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