Chapter 14-Payments (RA/EOB) Appeals and Secondary Claims
Key Words
Adjudication-Judges how a claim should be paid (processing) Steps: Initial processing, Automated Review,
Manual Review, Determination and Payment
Appeal-Sent to a Third Party after a questionable claim is transmitted. Non-par cannot appeal.
Appellant-Person filing a claim appeal
Auto Posting-Automatically posts payment to the patient’s account
Claimant-Person or entity who seeks to receive benefits
Claim Adjustment Reason Codes RC-Used to explain entries on a RA/EOB
Claim Status Category Codes-Provides more detail about the status of transmitted claims
Concurrent Care-Patient receiving extensive care from two or more providers on same date of service
Determination-Payers decision regarding payment of a claim. Pay, Deny or Partially pay a claim
Development-Payer needs more information to process a claim
Electronic Funds Transfer EFT-Electronically deposited into the practices bank account
Explanation of Benefits EOB
GRP Codes-Claim adjustment group codes
Grievance-File with state insurance commission requires state to investigate the complaint
Insurance Aging Report-List of claims transmitted each day and shows how long they have been in process
with the payer (unpaid)
Medical Necessity-Denial, Lack of clear, correct linkage between diagnosis and procedures
Medical Review-Established by third party payer
Medicare Redetermination Notice MRN-Explains Medicare’s negative response to a request for
redetermination
Medicare Outpatient Adjudication MOA-Explain adjustments to claims paid on RA/EOB
Medicare Secondary Payer MSP
Overpayments-Credits must be returned to the payer
Pending-Payer waiting for information before making a payment decision
Prompt-Pay-Laws-Obligate state licensed carriers to pay claims within a certain time frame
Remittance Advice RA-Group of claims
RA Remark Codes REM-Explain adjustment to claims paid on RA/EOB
Reason Codes –RC
Reconciliation-Making sure all totals on RA/EOB check out mathematically.
Ex-total amount billed-adjustment-patient responsibility=payment
Utilization Review-Conducted by payer to check medical necessity of claim after claim is transmitted