PAR Denial Management and Point of Service Collections Flashcards

What is a 'claim denial' in healthcare revenue cycle?

Answer: A refusal by an insurance payer to reimburse for a submitted claim, in whole or in part

A claim denial occurs when an insurer refuses to pay all or part of a claim, and the denial reason code tells the provider what went wrong.

What is 'timely filing' in the context of medical billing?

Answer: The deadline set by insurers within which a claim must be submitted after the date of service to be eligible for payment

Timely filing limits are deadlines imposed by each payer requiring claims to be submitted within a defined period after the date of service, and missed deadlines result in non-payable denials.

What does a denial reason code with the prefix 'CO' indicate?

Answer: A contractual obligation adjustment where the provider has agreed to write off the amount as part of their payer contract

The 'CO' prefix (Contractual Obligation) on a CARC code means the adjustment is due to a payer-provider contract, and the provider cannot bill the patient for that amount.

What does a denial reason code with the prefix 'PR' indicate?

Answer: Patient Responsibility — the amount the patient is expected to pay, such as a deductible, copay, or coinsurance

The 'PR' prefix (Patient Responsibility) identifies the portion of a claim the patient is expected to pay, including deductibles, copays, and coinsurance amounts.

What is the purpose of a 'remittance advice' (RA)?

Answer: A document sent by the payer to the provider explaining how a claim was adjudicated, including payment amounts and adjustment codes

A remittance advice details how each claim line was processed, showing billed amounts, allowed amounts, payer payments, adjustments, and reason codes for any denials or reductions.

What is a 'RAC audit' in the context of Medicare?

Answer: A Recovery Audit Contractor review that identifies and recovers improper Medicare payments made to providers

RAC (Recovery Audit Contractor) audits review Medicare claims to identify overpayments and underpayments, and providers must repay overpayments identified by RAC auditors.