Service ordered/ provided/ documented

1
Review for medical necessity of admission against
criteria
Inpatient claim flow
Concurrent review by CDI/coder working DRG
Service ordered/ provided/ documented
Chargemaster
Query to and from physician for increased
specificity
Organization appeals or writes off
Coding/DRG assigned
Billing/claim scrub/sync up with payer
requirements
Claim dropped to payer
Payer pays/denies all or part of claim
Post-payment audit (RAC, MIC, etc.)
2
Outpatient claim flow
Service ordered/ provided/documented
Chargemaster
Query to and from physician for increased
specificity
Organization appeals or writes off
Coding/DRG assigned
Billing/claim scrub/sync up with payer
requirements
Claim dropped to payer
Payer pays/denies all or part of claim
Post-payment audit (RAC, MIC, etc.)