Insurance Billing: Product Assessment Review (PAR)

Below is an overview of the metrics evaluated for all 14 payments within the posting category, with 4-7 scans being reviewed:

1. Payment totals are accurately applied, without any backdating.*
2. Adjustments are properly and correctly applied.*
3. Deductible amounts are accurately calculated and applied. *
4. The scan cover sheet is reconciled with the deposit report, or comprehensive notes are provided to explain any discrepancies.
5. Posting notes are complete, professional, and clearly documented.
6. Posting notes accurately reflect the patient portion and deductible applied, where applicable.
7. Scans are posted in their entirety within 24 business hours.*
8. EFTs are processed and posted by the end of the week.*
9. Claims that are denied, underpaid, or not paid as expected are thoroughly investigated and/or appealed within 5 days. Proper documentation of the appeal is maintained in the PMS, with all appeals followed up on within 5 days. *
10. Adaptability to specific office requests (e.g., VCCs) is demonstrated.

 * Notates RCM Critical

Below is an overview of the metrics evaluated for each item in the claim submission category, with at least 10 claims being assessed:

1. Claims are submitted on a daily basis.
2. All clearinghouse rejections are managed within 3 business days.
3. All required attachments are included prior to submission, along with comprehensive narratives and prior histories when applicable. 
   
   

Below is an overview of the metrics evaluated for each item in the aging claim category, with 10 claims being assessed:

1. If it’s is a new office with a large IAR, all claims to be worked within the
   first 90 days. Otherwise, all outstanding claims over 30 days receive a
   status update every 14-21 days (or as goals are specified).
   Ortho claims will not need a 14-21 day status follow up as long as there is a
   “metric” note placed.
2. Ensures high-quality aging claim management and avoids inefficient practices, such as repetitive "NOF, resent" submissions.
3. Clear, professional, and comprehensive notes are recorded for each claim.
4. Denied claims identified during the aging process are resubmitted within 5 days, with the denial status clearly documented and all required attachments included prior to re-submission.

Below is a checklist to ensure accurate reporting and data storage are maintained in accordance with client expectations. This is a team-shared category, meaning both team members will receive the same score in this section.

Below is an overview of the metrics evaluated for each item in the aging claim category, with 10 claims being assessed:

1. All outstanding claims over 30 days receive a status update every 14-21 days (or as specified).
2. Ensures high-quality aging claim management and avoids inefficient practices, such as repetitive "NOF, resent" submissions.
3. Clear, professional, and comprehensive notes are recorded for each claim.
4. Denied claims identified during the aging process are resubmitted within 5 days, with the denial status clearly documented and all required attachments included prior to re-submission.

Below is a checklist to ensure accurate reporting and data storage are maintained in accordance with client expectations. This is a team-shared category, meaning both team members will receive the same score in this section.