HCR 230 Week 6 DQ 1 - first trying a lower less invasive...

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For all service lines on a claim, the payer makes a payment determination a choice of whether to pay it, deny it, or pay it at a reduced level. If the service is paid, the services are within average guidelines. If it is not reimbursable, on the claim is deniable on the item. If the examiner decides that, the service was at excessively high a level for the diagnosis, and an assigned code at a lower level. When the level of service was cheap, the examiner has down coded the service. A medical need of denial may cause a result from a lack of clear, correct linkage between the diagnosis and procedure. A medical necessity denial can happen when an advanced level of service was provided without
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Unformatted text preview: first trying a lower, less invasive procedure. Some payers or polices require a patient to fail less invasive or more conservative treatment before more intense services are covered. If payment is due, the payer sends it to the provider along with a remittance advice (RA) or electronic remittance advice (ERA), a transaction that explains the payment decisions to the provider. In most cases, if the claim was e-mailed electronically, this transaction is also electronic; but it may sometimes be paper. An older term that now usually refers to the paper document is explanation of benefits (EOB). When the general term, RA/EOB it can mean both formats....
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