"Why is it important to review claims prior to submission? If a resubmission is needed, how do you determine the method to resubmit?"

There are a few key reasons it is important to review claims prior to submission:

 1. To double check the information submitted – This is in cases where there is an extra opportunity to ensure that all the necessary information has been availed, correct billing codes are used, all the necessary documents are attached among others, thus decreasing chances of the claim being rejected or delayed due to lack of information or wrong information.

 2. To complement revenue – This way, you get to scrub the claims to check the correct billing codes and modifiers, which will help you to enhance the reimbursement for the services offered. This enables you to get your maximum possible entitlement for the trip.

 3. To prevent fraud and abuse – This makes it easier to eliminate some mistakes that a client might have made in a claim that may be looked at as fraudulent or abusive in billing practices and might lead to an audit or penalties later.

 To what factor do you base how to resubmit the work in case of a resubmission?

 If a claim is denied and needs resubmission, there are a few factors to consider in determining the best resubmission method:

 1. Explanation of denial - Assess the denial of the benefits and find out that the reason why the claim was denied is what will help one to know how to refill it in the best manner.

 2. General information about the payers - Look up in each of the payer’s provider manuals to understand how they want resubmission if at all – be it on paper, electronically or through appeal.

 3. Additional Documentation required – Determine if there is necessary information from the patient record that needed for the resubmission and add as necessary.

 4. Time limit – Submit the claim within the agreed time frame for claiming by the payer to be regarded as on time. It typically takes 30 to 90 days for corrections to be made depending on the payer.