Claims Adjudication and Appeals

This unit focuses on the processes and documentation required to move a claim from submission to payment, including payer verification, remittance analysis, denials, and appeals. Students will practice applying coding and clinical documentation improvement (CDI) principles, Medicare/contractor rules, and audit techniques to ensure accurate, compliant reimbursement and prepare for certification and career steps.

Learning Objectives

• Analyze remittance advices, EOBs, and claim status reports to identify reasons for payments, denials, adjustments, and calculate provider and patient financial responsibility
• Apply payer verification procedures, plan coverage rules, ICD-10/CPT/HCPCS coding guidelines, and Medicare contractor policies to determine medical necessity, correct bundling, and appropriate claim submission
• Demonstrate end-to-end claims management by tracking sample claims from submission through payment, preparing and submitting timely appeals with supporting documentation, and communicating with payers and Medicare contractors
• Evaluate clinical documentation using CDI and audit tools to detect and correct overcoding, undercoding, unbundling, or insufficient documentation and recommend remediation and training/certification pathways for career readiness