Timely filing — definition · US Medical Billing

Reading a Payer Companion Guide

A payer companion guide is the per-payer instruction manual layered on top of the HIPAA transaction standards. Reading it well means knowing which sections are universal, which are payer-specific, and which explain the payer's permitted implementation requirements and payer-specific handling without replacing or overriding the applicable HIPAA/X12 implementation standard.

Updated July 18, 2026 · 6 min read

Denials & Appeals

What Is a Claim Denial?

A claim denial is a payer's decision, after adjudication, to refuse payment in whole or in part — and it is not the same thing as a rejection.

Updated August 2, 2026 · 8 min read

Denials & Appeals

Why Claims Get Denied

Denials cluster into a small number of recurring reasons — eligibility, authorization, medical necessity, coding, filing, and coverage order — each pointing back to a different step.

Updated August 2, 2026 · 9 min read

Denials & Appeals

Appealing a Denial: When, What, and How Long You Have

An appeal argues that the payer's decision was wrong. Knowing when to appeal rather than correct, and what evidence answers the reason given, is most of the outcome.

Updated July 16, 2026 · 9 min read

Denials & Appeals

Denial Prevention: The Controls That Work Upstream

Denials are produced by a process, and the controls that stop them sit before the claim is sent — in registration, authorization, documentation, and the feedback loop that closes.

Updated August 2, 2026 · 7 min read

Denials & Appeals

The Levels of Appeal: Where a Denial Goes Next

An upheld appeal is rarely the end of the matter. Medicare publishes five levels, Medicare Advantage forwards a case on automatically, and most commercial coverage adds an external review the plan does not decide.

Updated August 1, 2026 · 12 min read

Denials & Appeals

Who Can Appeal a Denial: Standing, Assignment, and Representation

An appeal filed by someone without the right to file it is dismissed on that ground alone, whatever its merits. Whether a practice may appeal in its own name turns on assignment, the plan's rules, and written authority from the patient.

Updated July 29, 2026 · 10 min read

Denials & Appeals

Duplicate Claim Denials: True Duplicate or Distinct Service?

A duplicate denial says the payer believes it already has this claim. The first move is never to resubmit — it is to find out whether the original paid, is still pending, or was itself denied, because each answer points to a different fix.

Updated July 29, 2026 · 10 min read

Denials & Appeals

Timely Filing Denials: Which Deadline Applied, and When There's an Exception

A timely-filing denial says the claim arrived after the filing window closed, so it never reaches the service. Before writing it off, settle two questions: which deadline actually applied, and whether the claim was truly late — because proof of timely receipt or a recognized exception can reopen it.

Updated July 30, 2026 · 11 min read

Denials & Appeals

Coordination of Benefits Denials: When the Payer Thinks Another Plan Is Primary

A coordination-of-benefits denial is the payer acting on its record of the patient's other coverage, not a coding error. Two denials hide under one label: the payer says another plan is primary and must pay first, or it cannot process a secondary claim because the primary's decision was not attached. The two have opposite fixes, so the first task is telling them apart on the remittance.

Updated July 30, 2026 · 12 min read

Denials & Appeals

Secondary Claim Denials: When the Second Plan Denies on Its Own Terms

A secondary claim is adjudicated by a second payer under its own contract, not paid out as a top-up of what the primary left. So a secondary that will not pay can mean three different things — a legitimate zero payment where coordination worked, a coordination-of-benefits breakdown, or a genuine denial the secondary made on its own coverage, network, authorization, or filing rules — and each is resolved a different way. Working one starts by reading the remittance to tell which it is, because re-sending the primary's explanation of benefits fixes only one of the three.

Updated July 30, 2026 · 10 min read

Denials & Appeals

Corrected Claim Denied Again: Why the Resubmission Failed

A corrected claim re-enters adjudication and is judged again — resubmitting is not the same as being paid. When one denies a second time, the cause is almost always that it never registered as a replacement, that it registered but never cured the reason the original was denied, or that the denial needed an appeal rather than a correction.

Updated July 30, 2026 · 11 min read

Denials & Appeals

Can You Bill a Patient for a Denied Claim? When You May and When You May Not

A claim the payer denied does not, by that fact, become the patient's to pay. Whether a denied balance may be moved to the patient is decided by three things read together — the group code the payer returned, the practice's contract with that payer, and whether the patient was told in advance and agreed to be responsible — and most denials are the practice's problem to solve, not the patient's bill.

Updated July 30, 2026 · 12 min read

Denials & Appeals

Prioritizing Denial Work: Which Denials to Work First

Denials arrive faster than a team can work them all at once, each carries a filing deadline that runs from the remittance, and not all of them are recoverable — so the order they are worked in decides how much is collected. Prioritizing denial work is the triage that reads each denial's disposition and deadline before its dollar value, then sequences a finite capacity against fixed windows.

Updated July 30, 2026 · 14 min read

Denials & Appeals

The Appeal Letter: What the Document Has to Contain

A reviewer decides on what is in front of them. The appeal letter is the container that carries the argument and its evidence there — and a correct argument that arrives unidentifiable, unsupported, or in the wrong queue loses like a wrong one.

Updated July 30, 2026 · 11 min read

Denials & Appeals

The Timely Filing Appeal Letter: The Two Arguments That Work

A timely-filing appeal can argue exactly two things: the claim was not late, or it was late for a reason the payer's own rules excuse. It can never argue the service. And under Medicare fee-for-service there is no appeal to file at all — which makes identifying the proceeding the first step, not the letter.

Updated August 7, 2026 · 11 min read

Denials & Appeals

Post-Service Peer-to-Peer Review: The Reviewer Call After a Denial

A post-service peer-to-peer is a clinician-to-clinician call about a claim that has already been denied — usually on medical necessity. It is not the pre-service authorization call, not every payer offers one after the service, and it never replaces the formal appeal: it is a faster route to the same independent physician review, run on its own short clock and converted into a paid claim only if it succeeds.

Updated July 30, 2026 · 11 min read

Denials & Appeals

Denial Write-Off Policy: Deciding When a Denied Balance Is Written Off

Writing off a denied balance is a decision, not a default — the point at which a practice stops pursuing a payer and clears the money from its books. A denial write-off policy separates the contractual adjustment the contract always expected from the avoidable write-off that is a real, recoverable loss, makes the write-off come last, and codes every one to its cause so the avoidable losses can be counted and cut rather than buried.

Updated July 30, 2026 · 13 min read

Denials & Appeals

Appeal Tracking and Follow-Up: Carrying a Filed Appeal to Resolution

Filing an appeal starts an obligation, not ends one: the payer now owes a decision on its own clock, and the window to take the appeal further runs from a decision the practice has to catch. Appeal tracking and follow-up is the discipline of carrying every filed appeal to a paid, escalated, or written-off resolution — so a filed appeal is not quietly lost to the payer's silence.

Updated July 30, 2026 · 14 min read

Claims

What Is a Medical Claim?

A medical claim is a structured request for payment that asserts who was treated, by whom, what was done, and why — and every part of it has to be supported.

Updated August 2, 2026 · 7 min read

Claims

The Claim Lifecycle: The Four Gates a Claim Passes

Between an encounter and a payment decision, a claim passes four gates — each owned by someone different, failing differently, and reporting somewhere else.

Updated August 2, 2026 · 7 min read

Claims

Submitting Claims: Routing and the Acknowledgment Chain

A claim reaches a payer through a clearinghouse or direct — and either way, the acknowledgments are the only thing that tells you it arrived.

Updated August 2, 2026 · 7 min read

Claims

Tracking a Claim: Status, Aging, and Follow-Up

An accepted claim that has not been decided is in neither process — and unlike a denial, nothing about it will ever ask for your attention.

Updated August 2, 2026 · 7 min read

Credentialing

Effective Dates: When a Provider Can Actually Bill

Four dates get confused, and only one decides whether a claim pays. The gap between a provider's start date and their effective date is where credentialing becomes a revenue problem.

Updated July 16, 2026 · 7 min read

Eligibility verification

What Is Eligibility Verification?

Eligibility verification confirms, before or at the visit, that a patient's coverage is active for the planned care — the first assertion on every future claim and the cheapest place to catch a coverage problem.

Updated July 18, 2026 · 4 min read

Eligibility verification

Identifying Primary and Secondary Coverage

When a patient has more than one health plan, coordination-of-benefits (COB) rules — not patient or staff preference — decide which plan is primary (billed first) and which is secondary. Identifying that order at registration matters because billing the wrong plan primary can trigger a denial even when the diagnosis and procedure coding are correct.

Updated July 18, 2026 · 7 min read

Eligibility verification

Eligibility-Related Denials and Their Causes

Eligibility-related denials are claim rejections that trace back to what coverage the patient had on the date of service and how it was recorded at registration. Most fall into a handful of categories: inactive or terminated coverage, the wrong plan or payer, coordination-of-benefits conflicts, non-covered services, and subscriber or member-ID mismatches.

Updated July 18, 2026 · 7 min read

Prior authorization

Precertification vs. prior authorization vs. predetermination

Precertification and prior authorization usually mean a required advance approval, while predetermination is a voluntary advisory review — and none of the three guarantees payment.

Updated August 2, 2026 · 6 min read

Prior authorization

Submitting a prior authorization request

Submitting a prior authorization request is the step in which a provider transmits a completed request and its supporting documentation to the payer through the payer's designated channel for review before the service is furnished.

Updated August 2, 2026 · 7 min read

Prior authorization

Tracking authorization status and deadlines

Tracking authorization status and deadlines is the ongoing work of monitoring each submitted prior authorization to a documented outcome while managing every date that can affect whether the resulting service is paid.

Updated July 18, 2026 · 9 min read

Prior authorization

Retroactive and urgent authorizations

Retroactive authorization seeks a payer's approval after a service is delivered, and urgent or expedited authorization is a faster review track for time-sensitive care — both are exceptions to obtaining prior authorization in advance.

Updated August 2, 2026 · 8 min read

Prior authorization

Matching authorized units to billed services

Matching authorized units to billed services is the reconciliation step that confirms a claim bills only the service, quantity, dates, provider, and site a payer's prior authorization actually approved.

Updated July 18, 2026 · 8 min read

Prior authorization

Prior authorization under Medicaid

Prior authorization under Medicaid is an advance-approval requirement whose specific rules, forms, and appeal procedures vary by state and by delivery model within federal limits, because Medicaid is a joint federal-state program administered through fee-for-service and managed care.

Updated August 2, 2026 · 9 min read

Prior authorization

Building a prior authorization tracking process

A prior authorization tracking process is the documented system a practice uses to log every request, follow it to a decision, and connect each approval to the claim it protects.

Updated July 18, 2026 · 8 min read

Prior authorization

Measuring prior authorization performance

Measuring prior authorization performance means tracking a defined set of metrics — turnaround, approval and rework rates, and downstream authorization-related denials — to see how reliably requests move through the process, with targets that vary by payer, plan, and date.

Updated July 18, 2026 · 8 min read

Prior authorization

Reducing authorization-related write-offs

Authorization-related write-offs are revenue a practice forfeits when a claim is denied for a missing, expired, or mismatched prior authorization; they trace to front-end gaps and can be reduced through prevention, disciplined recovery, and root-cause tracking.

Updated August 2, 2026 · 7 min read

Credentialing

Commercial payer contracting

Commercial payer contracting is the process by which a provider or group and a private health plan negotiate and execute a participation agreement that sets in-network terms for reimbursement and administration.

Updated July 18, 2026 · 8 min read

Credentialing

Credentialing gaps and enrollment-related denials

Credentialing and enrollment gaps occur when a provider renders services before enrollment is effective, after it lapses, or under an incorrect group affiliation. This article explains how those gaps generate claim denials, why effective dates and revalidation deadlines drive them, and how the concepts vary by payer, program, and state.

Updated July 18, 2026 · 6 min read

Medicare billing

How is Medicare structured? (Parts A, B, C, D)

A structural overview of the four parts of Medicare — Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage) — explaining how each part is administered, which claims pathway it uses, and why the distinctions matter for billing. Program rules, cost-sharing, and coverage vary by plan, jurisdiction, and effective date.

Updated July 18, 2026 · 7 min read

Medicare billing

Medicare Part A billing

An educational overview of how Medicare Part A institutional billing works — the facility services it covers, the UB-04/institutional claim format, benefit-period and cost-sharing structure, prospective payment systems, and the enrollment, eligibility, and coordination-of-benefits steps that shape a clean Part A claim.

Updated August 2, 2026 · 8 min read

Medicare billing

Medicare Part B billing

An educational overview of Medicare Part B billing: what Part B covers structurally, how professional claims are submitted to Medicare Administrative Contractors, and the enrollment, coverage, assignment, and remittance concepts that shape the process. Rules vary by contractor, service, and date; the article points to CMS as the authoritative source.

Updated August 2, 2026 · 7 min read

Medicare billing

Medicare Advantage (Part C) billing

Medicare Advantage (Part C) plans are private plans that administer Medicare benefits under contract with CMS, so claims are billed to the plan rather than the Medicare Administrative Contractor. This article explains how Part C billing differs from Original Medicare, including plan-specific enrollment, network and referral rules, prior authorization, cost-sharing, and appeals, and notes where rules vary by plan, contract, and date.

Updated August 2, 2026 · 9 min read

Medicare billing

The Medicare Beneficiary Identifier (MBI)

The Medicare Beneficiary Identifier (MBI) is the confidential, non-intelligent identifier that Medicare uses on cards and claims in place of the older Social Security-based number. This article explains what the MBI is, why CMS introduced it, how it appears in the revenue cycle, and where it fits alongside eligibility, claims, and denial workflows.

Updated August 2, 2026 · 6 min read

Medicare billing

Medicare timely filing

An educational overview of Medicare's timely filing requirement: the one-calendar-year fee-for-service limit set by statute, how it is administered through Medicare Administrative Contractors, the narrow exceptions set by federal regulation, and why counting conventions and Medicare Advantage deadlines should be confirmed against authoritative guidance rather than assumed.

Updated August 2, 2026 · 8 min read

Medicare billing

Medicare Part B drugs and biologicals

An educational overview of how Medicare Part B covers and pays for certain drugs and biologicals — including the average sales price payment framework, HCPCS Level II coding and billing units, discarded-drug reporting, coverage determinations, and the self-administered drug exclusion. Emphasizes that specific rates, lists, and rules vary by contractor, date, and program.

Updated August 2, 2026 · 9 min read

Medicare billing

Common Medicare billing denials

An educational overview of the denial categories that recur most often in Medicare billing — eligibility and identifier errors, coverage and medical-necessity determinations, enrollment and assignment issues, secondary-payer coordination, and timely-filing problems — with the authoritative sources that govern each and a note that specific rules vary by contractor, plan, and date.

Updated July 18, 2026 · 7 min read

Medicaid billing

How Medicaid works

A structural overview of Medicaid as a jointly funded federal-state program: how it is financed and administered, who qualifies, how services are delivered through fee-for-service and managed care, and how billing rules vary by state, plan, and date.

Updated July 18, 2026 · 7 min read

Medicaid billing

Fee-for-service vs. managed Medicaid

A payer-agnostic comparison of the two dominant Medicaid delivery models — fee-for-service, where the state agency pays claims directly, and managed care, where the state contracts with health plans — and how the distinction shapes enrollment, eligibility checks, claim routing, prior authorization, and denials. Every operational detail varies by state, program, plan, and date.

Updated July 18, 2026 · 8 min read

Medicaid billing

Medicaid eligibility categories

An educational overview of how Medicaid eligibility is organized into categories, why those categories matter for billing, and how they vary by state, program, and date.

Updated July 18, 2026 · 7 min read

Medicaid billing

Medicaid provider enrollment basics

Medicaid provider enrollment is the state-administered process that authorizes a provider to render and bill for services to Medicaid beneficiaries. Because Medicaid is jointly funded and state-administered, enrollment requirements, application systems, screening levels, and timelines vary by state and by program, so providers verify each state's specific rules.

Updated August 2, 2026 · 7 min read

Medicaid billing

The federal-state structure of Medicaid

Medicaid is jointly funded by the federal government and the states but administered by each state, which is why coverage rules, benefits, provider enrollment, and billing procedures differ from one jurisdiction to the next. This article explains that shared structure and why it drives so much program variation.

Updated August 2, 2026 · 6 min read

Medicaid billing

Medicaid timely filing

An educational overview of Medicaid timely filing: what the deadline means, how it is measured from the date of service, why limits vary by state and managed care plan within federal parameters, and how coordination of benefits and exception rules affect the filing clock.

Updated August 2, 2026 · 9 min read

Medicaid billing

Medicaid prior authorization

Medicaid prior authorization is the process by which a state Medicaid agency or its managed care plan reviews and approves certain services, drugs, or equipment before they are furnished. Federal regulation sets outer limits on how quickly standard and expedited requests must be decided, but which items require authorization, how requests are filed, and any shorter state timeframes vary by state, program, and plan, so providers verify current rules with the authoritative source.

Updated August 2, 2026 · 7 min read

Medicaid billing

Medicaid crossover claims

A Medicaid crossover claim is a claim that transfers from Medicare (or another primary payer) to Medicaid so the state program can consider any remaining patient responsibility. This article explains how automatic and provider-initiated crossovers work, the coordination-of-benefits infrastructure behind them, and the enrollment and filing conditions that vary by state.

Updated July 18, 2026 · 7 min read

Medicaid billing

EPSDT billing

EPSDT is the Medicaid benefit that covers comprehensive preventive, screening, diagnostic, and treatment services for enrolled children and adolescents under age 21. This article explains how EPSDT shapes coverage and billing, and why specific codes, screening schedules, and claim rules vary by state and plan.

Updated July 18, 2026 · 8 min read

Medicaid billing

Medicaid and CHIP

An educational overview of how Medicaid and the Children's Health Insurance Program (CHIP) relate to each other, how each is structured and administered by states within a federal framework, and why the distinctions between them affect eligibility, enrollment, and billing workflows.

Updated July 18, 2026 · 7 min read

Medicaid billing

Medicaid third-party liability

An educational overview of Medicaid third-party liability (TPL): the principle that Medicaid pays after other legally responsible payers, how TPL is identified and coordinated, and how billing workflows reflect Medicaid's payer-of-last-resort role. Rules vary by state, program, and date.

Updated August 2, 2026 · 8 min read

Medicaid billing

Medicaid claim submission basics

An educational overview of how Medicaid claims move from registration to payment, including the claim formats used, the roles of fee-for-service and managed care, and why submission rules vary by state, plan, and program.

Updated July 18, 2026 · 6 min read

Medicaid billing

Common Medicaid billing denials

An educational overview of the denial patterns that recur in Medicaid billing — eligibility, enrollment, prior authorization, coordination of benefits, coding, and timely filing — and why the underlying rules vary by state, program, and plan.

Updated July 18, 2026 · 6 min read

Behavioral health billing

Behavioral health billing overview

An educational overview of how behavioral health billing works in the United States, covering the professionals and settings involved, the code sets and documentation that support claims, coverage structures such as parity and carve-outs, and where payer, plan, state, and program rules commonly vary.

Updated July 18, 2026 · 7 min read

Behavioral health billing

Psychotherapy time-based billing

An educational overview of how outpatient psychotherapy is billed by time, how session-length code families are structured, what documentation supports a time-based service, and how the specific rules vary by payer, plan, state, program, and date.

Updated August 2, 2026 · 6 min read

Behavioral health billing

Billing for medication management

An educational overview of how psychiatric medication management is documented and billed, why it is often reported using evaluation and management concepts rather than psychotherapy, and how payer, plan, and jurisdiction rules shape coverage, prior authorization, and documentation.

Updated July 18, 2026 · 6 min read

Behavioral health billing

Substance use disorder billing

An educational overview of how substance use disorder (SUD) treatment services are documented and billed across the continuum of care, including code sets and their maintainers, medication-assisted treatment, confidentiality under 42 CFR Part 2, and why coverage, authorization, and reimbursement rules vary by payer, plan, state, and date.

Updated August 2, 2026 · 7 min read

Behavioral health billing

Medication-assisted treatment billing

An educational overview of how medication-assisted treatment (MAT) for substance use disorders is billed, including the interplay of medication and counseling components, bundled program structures, place-of-service and confidentiality considerations, and why specific rules vary by payer, plan, state, program, and date.

Updated August 2, 2026 · 7 min read

Behavioral health billing

Behavioral health parity

A payer-agnostic explanation of behavioral health parity: what mental health and substance use disorder parity means, how it shapes coverage terms and administrative rules, and why parity questions surface throughout the billing and revenue cycle. Parity standards, plan terms, and enforcement vary by payer, plan type, jurisdiction, and effective date.

Updated July 18, 2026 · 7 min read

Behavioral health billing

Behavioral health prior authorization

An educational overview of how prior authorization applies to behavioral health services — what it is, which services commonly require it, how carve-outs and parity affect the process, and how the request workflow is structured. Requirements vary by payer, plan, state, and date.

Updated July 18, 2026 · 7 min read

Behavioral health billing

Collaborative care model billing

An educational overview of how the psychiatric collaborative care model is billed, including the care-team structure, the monthly time-based approach used by Medicare and many payers, documentation and consent considerations, and how program, plan, and state variation shapes reimbursement.

Updated July 18, 2026 · 8 min read

Behavioral health billing

Behavioral health under Medicaid

An educational overview of how behavioral health services are covered, structured, and billed under Medicaid, including the federal-state framework, managed care and carve-out arrangements, provider enrollment, prior authorization, and documentation — with an emphasis on how rules vary by state, plan, program, and date.

Updated July 18, 2026 · 7 min read

Behavioral health billing

Behavioral health under Medicare

An educational overview of how Medicare organizes coverage, enrollment, and claims for behavioral health services across its parts and programs, with variation flagged to authoritative federal sources.

Updated July 18, 2026 · 7 min read

Behavioral health billing

Common behavioral health denials

An educational overview of the denial patterns that most often affect behavioral health claims — eligibility and carve-out issues, authorization gaps, documentation and medical-necessity findings, coding and time-based errors, and timely-filing lapses — with the qualification that specific rules vary by payer, plan, state, program, and date.

Updated July 18, 2026 · 7 min read

Behavioral health billing

Measuring the behavioral health revenue cycle

An educational overview of how behavioral health organizations measure revenue cycle performance — the metrics involved, the segmentation that behavioral health requires, and why benchmarks vary by payer, plan, state, and program.

Updated July 18, 2026 · 7 min read

Payer Contracts & Reimbursement

Reading a Payer Contract

Nobody reads a participation agreement front to back. You read it backwards from a question — and the agreement is usually larger than the document you signed.

Updated August 2, 2026 · 9 min read

Payer Contracts & Reimbursement

When a Payer Contract Changes

Three different things change your obligations under a payer agreement, and only one is an amendment. Which one it is decides what notice you were owed and what you can do.

Updated August 1, 2026 · 9 min read

Payer Contracts & Reimbursement

The Single Case Agreement

A one-off contract covering one patient's care with a payer the practice does not otherwise contract with. In most of the situations that produce one, the plan already owes the coverage — which changes what is being negotiated.

Updated August 1, 2026 · 9 min read

Payer Contracts & Reimbursement

Preparing a Payer Contract Renegotiation

Most of a renegotiation happens before anyone talks. The work is being able to state what the contract actually pays — which is not what the fee schedule says — and to say it in a form the other side can check.

Updated August 1, 2026 · 9 min read

Payer Contracts & Reimbursement

Terminating a Payer Contract: What Survives the End Date

Ending a payer agreement stops new in-network services and very little else. Patients mid-treatment, claims already filed, the clocks running on them, and whatever the agreement says survives all outlast the end date — and federal law treats simply letting the contract lapse as a termination too.

Updated August 1, 2026 · 12 min read

A/R & Follow-Up

Designing an A/R Follow-Up Process

Follow-up fails by design more often than by effort. Four decisions define the function — and the first, what makes an account workable, is a state rather than an age.

Updated August 1, 2026 · 11 min read

A/R & Follow-Up

What an A/R Aging Bucket Hides

The aging report answers one question and gets asked four. The bucket boundaries are a convention, the start date is a choice, and age is not a test of collectibility.

Updated August 1, 2026 · 11 min read

A/R & Follow-Up

The 276/277 Claim Status Transaction

The only follow-up mechanism that scales to a whole book of claims — and the one most misread, because what it returns is a position rather than an explanation.

Updated August 1, 2026 · 8 min read

A/R & Follow-Up

Payer Portal Claim Follow-Up

A portal is a substitute for a standard, not an instance of one. That explains why it is often the only place an answer exists, why it can never be the follow-up method, and why its logins are the practice's problem.

Updated August 1, 2026 · 10 min read

A/R & Follow-Up

Documenting a Follow-Up Call

A verbal answer binds nobody, so the only thing a call leaves behind is the note. Which means the note has to be built for the three jobs it will actually be asked to do.

Updated August 1, 2026 · 10 min read

A/R & Follow-Up

Unbilled and Held Claims: The Receivable No Report Shows

A claim that has not been submitted is still a receivable, and its filing clock started at the date of service rather than the day it became ready. Because aging is built from billed claims, this is the one part of the book that the report designed to surface risk cannot display at all.

Updated August 1, 2026 · 9 min read

A/R & Follow-Up

Provider Representative Escalation: Which Ladder Are You On?

Most escalations fail because they go up the wrong ladder. A wrongly decided claim, a payer rule producing wrong results at scale, and a disagreement about the contract are three different routes with three different audiences — and one question separates them.

Updated August 1, 2026 · 8 min read

A/R & Follow-Up

A/R at a System Conversion

A billing system conversion is the one routine event that can destroy a receivable without anyone touching a claim. Deadlines keep running while balances stop being visible, and the aging start date usually resets so the oldest accounts emerge looking the newest.

Updated August 1, 2026 · 11 min read

A/R & Follow-Up

No Response From the Payer

A claim with no response is four different failures wearing the same appearance: never arrived, rejected before adjudication, genuinely pending, or decided by a response nobody received. Only one of them is answered by asking again — and for an ERISA plan, a plan that will not decide has a consequence of its own.

Updated August 1, 2026 · 8 min read

A/R & Follow-Up

Aged Claims at Timely-Filing Risk

An aging report ranks claims by elapsed time, which measures the past. What decides whether work is worth doing today is the time remaining before a claim stops being collectible — and because filing windows differ by payer, those two orderings disagree.

Updated August 1, 2026 · 7 min read

Patient Billing & Collections

Billing a Deceased Patient's Estate

The balance survives the patient. The process for collecting it does not — statements, calls and agency placement have no legal effect against an estate, while a bar date measured from the date of death runs whether or not anyone tells the practice anything.

Updated August 1, 2026 · 15 min read

Coding, Modifiers & Edits

Unlisted Procedure Codes

An unlisted code has no price to be wrong about — the contractor builds one from what you sent. That single fact rearranges the claim, the appeal, and the global period, and it is why the narrative is the only lever there is.

Updated August 1, 2026 · 13 min read

Medicare billing

The Buy-and-Bill Model

Buy-and-bill is not a program or a strategy. It is what follows from one rule — a practice may bill for a drug it purchased and may not bill for one it did not — plus a second rule that forbids recovering any difference from the patient.

Updated August 7, 2026 · 11 min read

Patient Billing & Collections

Insurance Discovery for Self-Pay Accounts

Searching a self-pay balance for coverage is permitted and often obligatory. The parts that go wrong are the size of the question you ask, which nobody downstream will correct, and the clock that starts when the answer arrives — against a filing window that has not been waiting.

Updated August 1, 2026 · 14 min read

Coding, Modifiers & Edits

Modifier Order on a Claim Line

The rule that pricing modifiers go first is real, consequential, and not published as a national instruction anywhere. It comes from a claims system, and the reason it exists is that the fee schedule's pricing record has room for exactly one modifier.

Updated August 1, 2026 · 11 min read

In practice

Sources

Referenced in the Knowledge Base

Reading a Payer Companion Guide

What Is a Claim Denial?

Why Claims Get Denied

Appealing a Denial: When, What, and How Long You Have

Denial Prevention: The Controls That Work Upstream

The Levels of Appeal: Where a Denial Goes Next

Who Can Appeal a Denial: Standing, Assignment, and Representation

Duplicate Claim Denials: True Duplicate or Distinct Service?

Timely Filing Denials: Which Deadline Applied, and When There's an Exception

Coordination of Benefits Denials: When the Payer Thinks Another Plan Is Primary

Secondary Claim Denials: When the Second Plan Denies on Its Own Terms

Corrected Claim Denied Again: Why the Resubmission Failed

Can You Bill a Patient for a Denied Claim? When You May and When You May Not

Prioritizing Denial Work: Which Denials to Work First

The Appeal Letter: What the Document Has to Contain

The Timely Filing Appeal Letter: The Two Arguments That Work

Post-Service Peer-to-Peer Review: The Reviewer Call After a Denial

Denial Write-Off Policy: Deciding When a Denied Balance Is Written Off

Appeal Tracking and Follow-Up: Carrying a Filed Appeal to Resolution

What Is a Medical Claim?

The Claim Lifecycle: The Four Gates a Claim Passes

Submitting Claims: Routing and the Acknowledgment Chain

Tracking a Claim: Status, Aging, and Follow-Up

Effective Dates: When a Provider Can Actually Bill

What Is Eligibility Verification?

Identifying Primary and Secondary Coverage

Eligibility-Related Denials and Their Causes

Precertification vs. prior authorization vs. predetermination

Submitting a prior authorization request

Tracking authorization status and deadlines

Retroactive and urgent authorizations

Matching authorized units to billed services

Prior authorization under Medicaid

Building a prior authorization tracking process

Measuring prior authorization performance

Reducing authorization-related write-offs

Commercial payer contracting

Credentialing gaps and enrollment-related denials

How is Medicare structured? (Parts A, B, C, D)

Medicare Part A billing

Medicare Part B billing

Medicare Advantage (Part C) billing

The Medicare Beneficiary Identifier (MBI)

Medicare timely filing

Medicare Part B drugs and biologicals

Common Medicare billing denials

How Medicaid works

Fee-for-service vs. managed Medicaid

Medicaid eligibility categories

Medicaid provider enrollment basics

The federal-state structure of Medicaid

Medicaid timely filing

Medicaid prior authorization

Medicaid crossover claims

EPSDT billing

Medicaid and CHIP

Medicaid third-party liability

Medicaid claim submission basics

Common Medicaid billing denials

Behavioral health billing overview

Psychotherapy time-based billing

Billing for medication management

Substance use disorder billing

Medication-assisted treatment billing

Behavioral health parity

Behavioral health prior authorization

Collaborative care model billing

Behavioral health under Medicaid

Behavioral health under Medicare

Common behavioral health denials

Measuring the behavioral health revenue cycle

Reading a Payer Contract

When a Payer Contract Changes

The Single Case Agreement

Preparing a Payer Contract Renegotiation

Terminating a Payer Contract: What Survives the End Date

Designing an A/R Follow-Up Process