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First, here are some useful definitions of terms.
  • Allowed Amount
  • Allowed Amount = Insurance Paid + Copay + Deductible + Coinsurance
  • Denial
  • Claim has $0 allowed amount as a whole
  • Partial Denial
  • At least one procedure has an allowed amount greater than $0, AND
  • One or more of the procedures is denied entirely
  • Unresolved Balance
  • Every procedure has an allowed amount greater than $0, BUT
  • Despite those allowed amounts, some portion of the charged amount has been denied on at least one procedure- Example: An encounter has a procedure with 50paid,50 paid, 25 contractual adjustment, and $5 denied CARC
Walkthrough: Partial Denials When dealing with partial denials, you have two options:
  • Modify and resubmit the claim
  • Adjust or write off the remainder Let’s look at an example case.
To find partial denials, filter the encounters on your Claim Details page by ‘Encounter Stage Reason,’ then select ‘Partial Denials.’ Upon clicking into one of the partially denied encounters, we can see which procedure was denied based on a few clues:
  • It has an outstanding balance, written in red
  • Its ‘PR Status’ is listed as ‘Provisional’ (hover your cursor over this status to see a tooltip explanation)
  • The encounter’s overall ‘Status’ is listed as ‘Not Balanced’
Click the arrow next to the procedure to see further details. In this case, the red highlighted explanation indicates that the procedure code is inconsistent with the modifier used. If we were to resubmit the claim, the modifier would need to be modified. See these guides for further instruction on resubmission: Unresolved balances appear on encounters when payers send partial or unclear remittances. These cases require action on your part. When dealing with unresolved balances, you have two options:
  • Modify and resubmit the claim
  • Adjust or write off the remainder To find unresolved balances, filter the encounters on your Claim Details page by ‘Encounter Stage Reason,’ then select ‘Unresolved Balances.’
Upon clicking into one of the encounters with an unresolved balance, we can locate the procedures responsible based on a few clues:
  • They have an outstanding balance, written in red
  • Their ‘PR Status’ is listed as ‘Provisional’ (hover your cursor over this status to see a tooltip explanation)
  • The encounter’s overall ‘Status’ is listed as ‘Not Balanced’
Click the arrow next to a procedure to see further details. In this example, we can see the PI-59 adjustment of $6.84 was made based on multiple or concurrent procedure rules (like surgery or diagnostic imaging with concurrent anesthesia). Now, you get to decide whether to modify and resubmit this claim or write it off! If you find yourself performing the same action repeatedly to resolve many encounters, it could be worth consulting with your account manager about setting up a rule to handle those cases. This may involve setting up Target Allowed Amounts [sic], so that the engine can close encounters with procedures that have been paid at or above a certain threshold of your choosing. See these guides for further instruction on resubmission: