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ValeriusBayesNewbySeggern: Medical Insurance: An Integrated Claims Process Approach, Third Edition V. Payment Processing Introduction The McGrawHill Companies, 2008 Chapter 14 Payments (RAs/EOBs), Appeals, and Secondary Claims Chapter 15 Patient Billing and Collections ValeriusBayesNewbySeggern: Medical Insurance: An Integrated Claims Process Approach, Third Edition V. Payment Processing 14. Payments (RAs/EOBs), Appeals, and Secondary Claims The McGrawHill Companies, 2008 448 Payments (RAs/EOBs), Appeals, and Secondary Claims C H A P T E R O U T L I N E Claim Adjudication Monitoring Claim Status The Remittance Advice/Explanation of Benefits (RA/EOB) Reviewing and Processing RAs/EOBs Appeals, Postpayment Audits, Overpayments, and Grievances Billing Secondary Payers Learning Outcomes After studying this chapter, you should be able to: 1. Describe the steps payers follow to adjudicate claims. 2. List ten checks that automated medical edits perform. 3. Describe the procedures for following up on claims after they are sent to payers. 4. Identify the types of codes and other information contained on an RA/EOB. 5. List the points that are reviewed on an RA/EOB. 6. Explain the process for posting payments and managing denials. 7. Describe the purpose and general steps of the appeal process. 8. Discuss how appeals, postpayment audits, and overpay- ments may affect claim payments. 9. Describe the procedures for filing secondary claims. 10. Discuss procedures for complying with the Medicare Sec- ondary Payer (MSP) program. ValeriusBayesNewbySeggern: Medical Insurance: An Integrated Claims Process Approach, Third Edition V. Payment Processing 14. Payments (RAs/EOBs), Appeals, and Secondary Claims The McGrawHill Companies, 2008 CHAPTER 14 Payments (RAs/EOBs), Appeals, and Secondary Claims 449 Claim follow-up and payment processing are important procedures in billing and reimbursement. Medical insurance specialists track claims that are due, process payments, check that claims are correctly paid, and file claims with sec- ondary payers. These procedures help generate maximum appropriate reim- bursement from payers for providers. Claim Adjudication When the payer receives claims, it issues an electronic response to the sender showing that the transmission has been successful. Each claim then undergoes a process known as adjudication , made up of steps designed to judge how it should be paid: 1. Initial processing 2. Automated review 3. Manual review 4. Determination 5. Payment Initial Processing Each claims data elements are checked by the payers front-end claims pro- cessing system. Paper claims and any paper attachments are date-stamped and entered into the payers computer system, either by data-entry personnel or by the use of a scanning system. Initial processing might find such problems as the following: The patients name, plan identification number, or place of service code is wrong.... View Full Document

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