Preparation tool
Give every claim review Work through the evidence your process needs. Check off the steps you have reviewed and download the remaining items.
Use this as a process checklist. Keep patient and claim identifiers in your approved secure system.
12 review checkpoints Checkpoints reviewed here are not a payer approval or a guarantee of payment.
01 · Confirm scope Identify the payer, program, jurisdiction, service period, claim format and submission route. 02 · Locate source records Confirm the required referral, authorization, invoice and service evidence are available in the approved secure system. 03 · Compare identifiers Check member and submitting provider identifiers against the appropriate authoritative record. 04 · Review authorization evidence Where applicable, compare services, dates and units with the received authorization and current payer instructions. 05 · Check claim fields Review required fields, dates, units and modifiers against the applicable claim format and payer rules. 06 · Verify the rule source Confirm the program, source section, effective period and any relevant updates. 07 · Resolve review questions Have a billing reviewer decide corrections and document any unresolved exceptions. 08 · Retain transmission evidence Keep the actual sending confirmation and correlation reference. A generated file is not a submission. 09 · Read acknowledgments Identify the sender, status and submission attempt for each response. 10 · Assign follow-up Record the next action, owner and payer-specific deadline source in your secure workflow. 11 · Reconcile remittance and cash Match claim and line details to the ERA/EOB, then reconcile the bank receipt separately. 12 · Close with evidence Confirm the documented outcome before closing an item. Silence alone does not establish denial or payment.
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