Claims Management and Payer Adjudication
Domain 4: Claims Management and Payer Adjudication
This domain covers claim creation (837P/837I), clearinghouse edits, payer adjudication, remittance (835), CARC/RARC, and coordination of benefits.
Core rules
- A clean claim contains required and valid data; front-end edits catch demographic, eligibility, and coding errors.
- The 277CA acknowledges acceptance; it is not payment.
- Adjudication: allowed amount equals the contracted rate; deductible, coinsurance, and copay apply; contractual adjustment equals billed minus allowed.
- CARC groups: CO (contractual), PR (patient responsibility), OA (other adjustment), and CR (correction/reversal).
- CO-45 is contractual; PR-1 is deductible; PR-2 is coinsurance; PR-3 is copay.
- Timely filing limits vary by payer and contract; track filing deadlines.
- Secondary claims use coordination of benefits; Medicare crossover may be automatic.
Worked example
A claim is billed at $1,200; the allowed amount is $600; the deductible is $200; coinsurance is 20% of the remaining $400 = $80. The plan pays $320. The patient owes $280. The contractual adjustment is $600 (CO-45). Posting the $600 as a denial or as patient responsibility distorts AR and collection.
Traps
Treating CO-45 as a denial; misreading PR versus CO; missing timely filing; ignoring RARC; billing secondary before primary adjudication; not checking eligibility.