Healthcare Claims Processing and Denial Management

Vocabulary flashcards covering the stages of claims processing, aging buckets for outstanding balances, and steps in denial management.

Claims Submission

The stage where a claim is sent electronically or manually to the payer.

Claims Processing

The stage where the payer sorts the claim and verifies patient/provider information.

Claims Adjudication

The stage where the payer checks benefits, coverage, eligibility, and claim accuracy.

Payment / Payer Response

The stage where the provider receives payment, denial, or adjustment information, and the patient receives an EOB.

Identification (Denial Management)

The denial management step focused on spotting the denied claim.

Management (Denial Management)

The denial management step focused on correcting errors or gathering needed documentation.

Monitoring (Denial Management)

The denial management step focused on tracking denials in logs.

Prevention (Denial Management)

The denial management step focused on educating staff and improving processes to reduce repeat errors.

Peer Review / Peer-to-Peer Review

A process in which a provider or medical director reviews the denial decision with the payer when appropriate.

Aging Buckets

Time frames used to track outstanding balances, categorized as 30 days, 60 days, 90 days, and 120+ days.