Important tasks | When | Key Points (How to execute task?) | Reason (Why execute task?) |
Identify type of claim response
| Upon receipt of notification (14-30 days after claim submission)
| - Identify if payment is approved or denied
- Identify Medicare Remittance Advice (RA) remark codes [4]
- If denied, identify if "Errors and Omissions" are Minor or Major Denial
| Prompt attention to claims payment or denial leads to improved revenue cycle
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If payment approved, process Payment
| Upon receipt of notification (14-30 days after claim submission)
| - Apply payment to the line item,
- Apply adjustments
- Forward coinsurance to the secondary payer or apply to patient balance if no secondary insurance
| Prompt attention to claims payment or denial leads to improved revenue cycle
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If "Minor" Denial, correct immediately and resubmit the claim [5]
| Correct within 1-3 days after notification is received
| - Investigate reason for denial based on denial codes adjust claim as appropriate (e.g., not a covered service)
- Refer to medical chart documentation as needed
- Edit claim and make addendum as needed
- Resubmit claim and addendum
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If "Major" Denials, investigate, forward denial to stakeholders
| Correct within 2-3 weeks after notification is received
| - For cellular based tissue products (CTP) or hyperbaric oxygen therapy (HBO) denials forward to nurse manager of HBO/wound clinic. For all other denials forward to the appropriate stakeholder
- Refer to medical chart documentation
- Check trends for denied charges (are you consistently getting denials for CTP? If so, investigate)
| Major denials often represent a significant loss of revenue. Correction and resubmission can result in significantly improved revenue
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If "Major" Denial is related to HBO, conduct chart and claim audit
| Correct within 2-3 weeks after notification is received
| | Major denials often represent a significant loss of revenue. Correction and resubmission can result in significantly improved revenue
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If "Major" Denial is related to CTP, conduct chart and claim audit
| Correct within 2-3 weeks after notification is received
| - Verify CPT code is correct and supports the services performed
- Verify date, time and location of the ulcer treated with CTP
- Verify the name of the CTP and how it was supplied
- Verify the amount of product units used
- Verify the amount of product units discarded
- State the reason and amount of wastage in units (This must be documented in the provider's note)
- Determine if your local MAC requires reporting of CTP wastage using the JW Modifer on the billing claim. The JW modifier is required in physician offices
- Ensure manufacturer's serial/lot/batch or other unit identification number of graft material is documented in the chart. [6]
- Make amendments as needed
- See topic "Cellular and/or Tissue Products"
| Cellular-based tissue products are high-cost items for wound clinics. Accurate complete record documentation and billing by the physician or other qualified health professional is the best way to ensure appropriate payment and to reduce the risk of any repayment following an audit. [6]
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Resubmit the claim
| Within 2-3 weeks after notification is received
| - Electronic submission with associated attachments as needed
- Prompt attention to claims payment or denial leads to an improved revenue cycle
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