Provider enrollment and affiliations
Participation status, effective dates, group linkage, service location and taxonomy can determine whether a provider is eligible to bill the payer for the service.
Patient eligibility and benefits
Coverage dates, product type, network rules, coordination of benefits and service-specific limitations should be confirmed before treatment and again when coverage may have changed.
Authorization controls
Approved dates, codes, units, servicing providers, place of service and expiration dates must align with the submitted claim.
Documentation and coding
Documentation must support the billed service, duration, provider type and payer requirements. Coding decisions remain a clinical and compliance responsibility and should not be changed solely to force payment.
Claim configuration
Billing provider, rendering provider, identifiers, modifiers, taxonomy, location and payer routing can create denials even when the service itself was appropriate.
Timely filing and follow-up
Rejections, requests for information and unresolved claims can consume filing or appeal time. Every account should have an owner, next action and deadline.
Payment and adjustment handling
Incorrect adjustments, unapplied payments or unposted remittances can make resolved claims appear unpaid and distort denial or A/R reporting.
Turn the findings into clear next actions.
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