Claims, Denials, and Appeals

Appeal

The process a provider uses to request that the payer reconsider a denial of payment on a claim.

Claims adjustment reason codes (CARCs)

A code on an EOB that describes why a claim or a line item on a claim was paid differently than it was billed or was denied altogether.

Denial

A payer’s refusal to provide payment and the return of the claim unpaid for any of several reasons.

Issue, Rule, Analysis, and Conclusion

A way of organizing a legal discussion so your reader will understand and be persuaded by your argument.

Root Cause

The core issue that sets in motion a reaction that ultimately causes a particular problem.

Root Cause Analysis

A problem-solving process that leads to the root cause of a problem so it can be addressed.