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lesson eight we'll talk about claim problems and a lot of the common coin codes and what we have to do to resolve claim problems when claims are processed electronically they go through multiple claim checks they may be checked by the practice management software before being transmitted when they're transmitted to the Clearinghouse when the chording else receives them they'll usually scrub or check a clean batch of claims when they're transmitted from the Clearinghouse to the insurance payer the payer has certain criteria before accepting a claim for payment or for processing and even when accepting for processing the claim still has to go through the insurance adjudication process and even during this process it could be adjusted or denied due to coding issues when a claim does get rejected denied the provider does not get paid at all so it's important to resolve clean problems as quickly as early in the process as you can because the longer claim because unpaid the less likely it is to be paid and anytime you have unpaid claims you're going to have an unhappy provider my claims don't get paid well typically clean rejections and denials fall into one of three categories there are the administrative type of areas those are incomplete information typographical errors data mismatches there are coding errors and there are documentation type errors now many times when the claims are transmitted from the practice to the Clearinghouse or from the clearing us to the payer a lot of those errors are administrative type of errors there are also areas that are detected when the claims being processed by the insurance payer and those are the codes that are indicated on the agreements advice or the explanation of benefits these areas are usually due to coding your documentation type of errors or errors where the payer needs to point information they can be administrative but it could be situations where the data doesn't match between the payer and the patient information of the provider information reason comes reason codes and insurance adjustments when insurance payment is adjusted after it's been accepted by the insurance payer there are reason or explanation codes that are provided on the remittance advice these are two types of codes they're the cart code the claim adjustment reason code and the Vark code the remittance advice remark codes all insurance payers are required under HIPAA laws to use identity standard for these codes that are explained all over minutes advice and there can be several adjustments on a-1 insurance payment that are given on an ER a or an EOB some common reasons for denial well to the glories and codes on an ER a describing one acquaintance was denied or incomplete claim information out of network provider failure to obtain pre-authorization the service was not determined to be medically necessary the benefit was not covered patients no longer covered preexisting was not covered by the patient's policy lower level of service was more appropriate the procedure and the diagnosis codes were incorrectly length or did not agree with each other the multiple codes were submitted that were included in a bundled service so these are many of the typical denial reasons that we see when claims are denied or adjusted from the insurance payer if you don't agree with the reasons you can appeal the claim and that should be done with additional explanation or additional documentation we'll talk a little bit more about the appeal process in just a minute when errors are detected the errors encountered at the Clearinghouse are when they're transmitted the claims are transmitted to the insurance payer don't follow the Clarke and Mark Convention codes parents usually have different conventions and explanations as to why crane was rejected before they'll accept it for payment and these can be very cryptic this can be very frustrating for a building specialist I know that's where we spent a lot of time as deciphering those codes and understanding them and looking for interpretation and you usually have to go to the payer and they'll have using a document a PDF type document in their website that will explain a lot of their errors and what's necessary to correct on the claim in order to get the acceptance by the payer however once these claims are accepted by the entrace payer any adjustments or denials should be explained using these standard kharkov our codes appealing a claim the claim appeal process is used when additional explanation or documentation will resolve an interns patient reason for why they're denying a claim or reducing the payment it's also used when you don't agree with what the payers giving you as a reason for this denial or just a payment the remittance advice typically will give you instructions for how to appeal claim but in most insurance payers have different processes for appealing or denied a claim europea produced claim some require a form to be completed and signed by the provider others may accept just a written letter of Appeal and provide instructions for doing that and still others may have an online appeal process that allows you to upload or send information electronically Medicare and other government payers they'll have a different appeal process that usually requires a standard form such as the you CMS 202 7 appeal form so the appeal process is very helpful in resolving unpaid claims or reduced payments for claims and it's a it's important to know how to navigate the appeal process for each payer we go into that in one more detail in our fundamental scores so that concludes lesson paint on claim issues and claim problems and how to resolve them and what some of the common reasons are for claim rejections and denials so next we'll be looking at lesson 9 posting and applying payments you