Case: outpatient specialty visit
A patient schedules an established-patient visit with a participating specialist. The account includes insurance information, an ordered diagnostic service and a payer authorization rule. After the encounter, the claim is submitted, adjudicated with an adjustment and leaves a patient responsibility amount.
Stage 1 - Before the visit
- Confirm demographics, subscriber data and active eligibility.
- Review network status, benefits and authorization requirements.
- Record any authorization number, effective dates, units/visits and service scope.
Stage 2 - Charge and claim preparation
- Confirm provider, place of service and encounter date.
- Verify that documentation supports the codes supplied by the authorized coding process.
- Check modifiers, units and claim edits.
Stage 3 - Adjudication
Read the remittance line by line: billed amount, allowed amount, payer payment, contractual adjustment, patient responsibility and any CARC/RARC information. Do not move a balance to the patient until the remittance and payer rules support it.
Stage 4 - Follow-up
Sample account note
Reviewed ERA dated 09/18. Claim processed; one line reduced under payer edit. Verified authorization covers DOS and service. Compared claim line to payer policy; correction required. Corrected claim prepared with supporting documentation. Follow-up set for 14 days. Ref: payer portal case ####.
Quick knowledge check
Where can a denial originate?
At multiple stages - registration, eligibility, authorization, documentation, coding, claim setup or payer adjudication.
What should happen before billing a patient balance?
Verify the remittance, benefits and payer rules support the patient responsibility.
Related services, tools & guides
Use these next-step resources to connect the lesson with real revenue-cycle workflows.
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