Billing Command Center

Complete before releasing the encounter

Standard flow

1. Provider completes and signs documentation.
2. Charges and diagnosis codes are reviewed.
3. The encounter is released to billing.
4. The claim passes internal and clearinghouse edits.
5. The payer accepts, rejects, pends, pays, or denies the claim.
6. Payment and contractual adjustments are posted.
7. Remaining patient responsibility is transferred appropriately.
8. Rejections and denials are corrected, appealed, or documented.

Important distinction

A rejected claim was generally not accepted into payer adjudication. A denied claim was processed and assigned a denial reason.

Verify and document

• Active coverage for the date of service.
• Patient name, member ID, group number, and date of birth.
• Copay, deductible, coinsurance, and out-of-pocket status.
• PCP assignment and referral requirements.
• Prior authorization requirements when applicable.
• Network status for the provider and location when available.
• Behavioral health carve-out or separate payer information.

Required standards

• Scan clear images of the front and back of every card.
• Enter the subscriber exactly as shown on the plan.
• Confirm the patient’s relationship to the subscriber.
• Use the correct payer entry and claims mailing address.
• Follow the naming format: Insurance Name – PO Box Number.
• Enter effective and termination dates when known.
• Confirm primary, secondary, and tertiary order.
• Create or update the correct case before scheduling or billing.

General use

Established patient office or outpatient visit typically supported by moderate medical decision-making or qualifying total time on the date of service.

Documentation should support

• The conditions evaluated and their status.
• Relevant records, tests, or data reviewed.
• Medication management or other treatment decisions.
• Risk associated with the conditions or treatment plan.
• Total time when coding based on time.

Common codes

Common documentation elements

• Health risk assessment.
• Medical and family history review.
• Current providers and suppliers.
• Measurements and cognitive assessment.
• Depression and functional screening.
• Personalized prevention plan and screening schedule.

Common coding references

Document

• Impacted cerumen and affected ear.
• Symptoms or clinical reason for removal.
• Method used: irrigation, lavage, or instrumentation.
• Who performed the procedure.
• Patient tolerance and post-procedure findings.

Common causes

• Missing or invalid modifier.
• Incorrect member or subscriber information.
• Missing rendering or referring provider data.
• Incomplete diagnosis or procedure information.
• Missing NDC, units, or authorization number.

Resolution steps

1. Review all accompanying remark codes.
2. Compare the claim to the encounter and payer requirements.
3. Correct the missing or invalid data.
4. Submit a corrected claim using the appropriate frequency type.
5. Document the action taken and follow-up date.

Review

• National Correct Coding Initiative edits.
• Whether the service is part of a global package.
• Whether the procedures were distinct and separately supported.
• Whether a modifier is clinically and documentation-supported.

Before creating or selecting a case

• Confirm active coverage and order of benefits.
• Confirm the payer and claims address.
• Review existing cases to prevent duplicates.
• Use a self-pay or approved Zero Pay case only when appropriate.
• Confirm the case is active for the date of service.

Workflow

1. Open the completed patient encounter.
2. Confirm the correct patient, provider, location, and case.
3. Review diagnosis and procedure codes.
4. Confirm each charge is linked to the supporting diagnosis.
5. Check modifiers, units, medication details, and notes.
6. Confirm the provider note is signed.
7. Release the encounter to billing.
8. Resolve any system edits instead of bypassing them.

Examples

• Duplicate encounters.
• Administrative or test encounters.
• Encounters intentionally designated as no-charge.
• Visits that did not occur.
• Other encounters approved as non-billable.

Reference pricing

• New Patient Visit: $150
• Established Patient Visit: $100
• Annual Physical: $150
• Telehealth Visit: $75
• Nurse Visit: $30
• Sports Physical: $35
• EKG Add-On: $30
• Ear Lavage: $40
• Nebulizer Treatment: $30
• Injection Administration: $20

Standards

• Post payments to the correct patient and date of service.
• Confirm whether funds are copay, self-pay, balance, or deposit.
• Do not leave credits unapplied without documented follow-up.
• Review payer processing before refunding an apparent overpayment.
• Use the approved refund workflow and authorization process.
• Document payment-plan arrangements clearly.