Pre-Auditing And Tracking Claims Operation Guides (The American Medical Association (AMA))

Pre-Auditing Claims is available for practice management software systems, clearinghouses, billing services or other claims transmission vendors for missing or incorrect information (such as an invalid patient identification number, a diagnosis code that is no longer valid or gender misidentification) prior to their submission to a payer. A pre-audit claim check for these types of potential claim issues can help expedite claim processing and reduce payment delays or denials by a payer. Pre-auditing claim checks may also allow for automatic cross-referencing of procedures according to a health plan’s requirements to help ensure that only approved procedures are submitted. Verifying electronic claims for accuracy before they are submitted to a payer decreases the time spent on claim review and adjustment, and allows for more timely claims processing and payment by a payer.

Tracking claims

The physician practice is encouraged to request claim transmission status reports from a payer, clearinghouse or other claims transmission vendor. These reports will supply the practice with an electronic audit trail to assist in tracking the accepted or rejected status of all the electronic claims sent to the various payers. When the physician practice is notified of a claim rejection electronically, it can quickly and easily correct and resubmit the claim electronically. Manual claim rejections, on the other hand, are received by the physician practice via mail and offer a paper copy of the payer’s explanation of benefits (EOB) form. Based on the information presented on the EOB, the physician practice must then research, correct and resend a revised manual claim via mail to the payer. This process can add several weeks to the physician practice’s accounts payable cycle.

Clearinghouse reports will typically list the patient’s name, the date of service, the AMA Current Procedural Terminology (CPT®)3 and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes on the claim, in addition to the payer information and the claim acceptance or rejection remark. The remark description is the stated reason the electronic claim was rejected by the payer.

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