Claims Denials and Appeals Practice Flashcards

These vocabulary flashcards cover the fundamental terms and concepts associated with medical claims denials and the appeals process as outlined in the training transcript.

Rejection

A status that usually happens before the payer fully adjudicates a claim, often caused by front-end submission problems like missing subscriber IDs or invalid code formats.

Denial

A status that occurs after the payer receives and processes a claim but decides not to pay for one or more services due to lack of coverage, medical necessity, or other policy issues.

Partial Denial

A situation in which part of a claim is paid and another service line is denied or reduced.

Underpayment

When a claim is processed as payable, but the payment amount is below the contracted rate or the payer's policy allowance.

Clean Claim

A claim that is submitted with all required data elements and enters the payer's payment system for adjudication without front-end errors.

Coordination of Benefits (COB)

The process of determining the primary and secondary payer order when a patient is covered by two or more insurance plans.

Prior Authorization

A pre-service rule requiring the provider to obtain approval from the insurance payer before performing specific services like imaging, surgery, or therapy.

Credentialing Issues

Denials related to the payer not recognizing the rendering provider, billing provider, or facility as enrolled or active in their system.

Medical Necessity

The standard that a service is reasonable and necessary based on the patient's condition, symptoms, and documented findings.

ICD-10-CM Pointers

The claim data elements that link specific diagnosis codes to the procedures performed to justify medical necessity.

Modifier 25

A modifier used to indicate a significant, separately identifiable evaluation and management (E and M) service by the same physician on the same day as a procedure.

Modifier 59

A modifier used to identify distinct procedural services, such as separate sites or encounters, to prevent improper bundling denials.

National Correct Coding Initiative (NCCI)

A set of edits designed to prevent unbundling and inappropriate separate payment for services that are considered components of a more comprehensive service.

Medically Unlikely Edits (MUE)

Payer edits that compare the billed number of units against expected maximums for a specific healthcare code.

Timely Filing

Deadlines set by payers for the receipt of original claims, corrected claims, or appeals; missing these eliminates recovery opportunities.

Duplicate Claim Denial

A denial issued when a payer believes the claim has already been processed or is currently pending in their system.

Place of Service (POS)

A code that tells the payer where care was delivered (e.g., office, ER, or hospital), which affects fee schedules and adjudication logic.

Electronic Remittance Advice (ERA)

The electronic version of the explanation of benefits (EOB) which includes reason and remark codes explaining the payer's payment decisions.

Corrected Claim

A resubmission used when the provider side made an error that can be fixed directly, such as a wrong diagnosis, missing modifier, or incorrect units.

Appeal

A structured request asking a payer to reconsider its decision when the original claim was correct but was misprocessed or denied despite documentation support.

Appeal Narrative

A professional, evidence-based letter that connects clinical findings to payer criteria to justify why a denied service should be paid.

Root-Cause Analysis

The practice of using denial data patterns (such as eligibility or modifier errors) to identify and improve weaknesses in the upstream revenue cycle.

Medicare Crossover

A process where primary adjudication data is automatically transmitted from Medicare to a secondary insurance payer.

Additional Documentation Request (ADR)

A request from a payer for medical records to review a claim before adjudication or during a post-payment audit.

Adjustment Group Code

A code on the remittance advice that identifies whether a balance is a contractual adjustment, patient responsibility, or another category.