NHA CBCS cheat sheet

Clean claim: submitted with all required data elements complete and accurate so it can be processed without payer development (request for more information).

Claim form selection: CMS-1500 for noninstitutional providers (physicians, suppliers); UB-04/CMS-1450 for institutional facilities (hospitals, SNFs, home health).

Timely filing: each payer contract and Medicare Administrative Contractor sets a filing limit; Medicare fee-for-service generally requires claims within 12 months of the date of service.

Coordination of benefits order: the primary payer is billed first; the secondary payer receives the primary's EOB/ERA or remittance advice with the claim.

NCCI edits: Column 1/Column 2 pairs deny the Column 2 code as bundled; modifier indicator 0 means no override, indicator 1 permits an appropriate modifier such as 59 or X{EPSU}.

Global surgical package: Medicare includes preoperative, intraoperative, and postoperative care; a separately reported E/M within the global period requires a documented modifier (24, 25, 57, or 79).

Claim appeal levels (Medicare Part B): redetermination by the MAC, then reconsideration by a Qualified Independent Contractor, then ALJ hearing, then Medicare Appeals Council, then federal court.

Claim status categories: paid, denied (no payment for the service), rejected (not processed due to data error), and pending/in-process; only denials carry appeal rights.

Claim scrubber edits run before submission to catch missing NPI, invalid diagnosis-to-procedure linkage, and eligibility failures, reducing rejection rates.

Patient responsibility balance = total allowed amount − payer payment; allowed amount is the lesser of the billed charge or the fee schedule/contract rate.

Adjusted contractual obligation (write-off) = billed charge − allowed amount; this amount is not billed to the patient.

Copay is a fixed dollar amount due at time of service; coinsurance is a percentage of the allowed amount; deductible is the amount paid by the patient before the plan pays.

ERA (835) is the electronic remittance advice used for automated posting; EOB is the paper or patient-facing explanation of benefits.

Payment posting order: post payer payment and contractual adjustment first, then transfer the remaining balance to patient responsibility.

Aging buckets commonly used: 0–30, 31–60, 61–90, 91–120, and 120+ days from the date of service or first statement.

Refund rule: when a payer or patient overpays, the overpayment is refunded or offset; Medicare overpayments must be reported and returned within 60 days of identification.

Patient statements are typically generated on a cycle (e.g., 30 days) after insurance adjudication; a self-pay account may require a deposit or payment plan.

Denial follow-up: track denial reason codes (CARC) and remark codes (RARC) to route work queues for correction, appeal, or patient billing.