Bill the right amount. Check what was paid.
Validate charges against the encounter and your payer rules, then compare payments with contracted rates.
2084P0800XNPI 1043…90868 mod 95| CPT | Mod | Allowed |
|---|---|---|
90867 | — | $300.00 |
90868 | 95 | $175.00 |
99214 | 95 | $200.00 |
Resolve missing or conflicting claim data.
Check the clinical record as well as the claim format.
Missing identifiers include member IDs, rendering NPIs, and authorization numbers.
Unsupported codes are flagged when the note conflicts or supports a more specific code.
Payer prerequisites include the evidence required for the service, such as prior treatment trials.
Recover payments below contract.
Compare each payment with the expected amount. Route the difference for follow-up and recovery.
Apply the right charge rules per payer.
Keep fee schedules and encounter-level coding rules outside the manual claim-editing cycle.
Provider taxonomy is configured per payer and refreshed from the CMS source.
CPT and modifier pricing follow your payer-specific fee schedules.
Add-on and clinical-status rules are applied to each encounter.