Billing team guide
What to Send
For IDR Review
Your 835 remittance shows how a payer handled the claim. An IDR reviewer also needs the underlying claim, notices, and coverage information. Here is what to gather before sending a case for review.
What an 835 tells you
An electronic remittance advice (ERA) explains claim payment and adjustments. The adopted ERA standard is the X12 835. Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) help explain payment adjustments. See CMS guidance on EFT and remittance advice.
A payment adjustment may warrant a closer look. To assess eligibility, the reviewer still needs to understand the plan, service circumstances, governing law, notice dates, and any prior dispute activity. No single remittance code answers all of those questions.
Keep the claim and service lines connected
Use a stable internal reference to join the submitted claim, payer claim number, service lines, and later correspondence. Preserve both billing and rendering provider identifiers where relevant. A corrected claim or a reprocessed payment should remain connected to the original record.
Check that service dates, codes, modifiers, units, and place of service agree across the available documents. Flag differences for review rather than overwriting the source record to make a spreadsheet match.
Preserve notices and their dates
Retain the initial payment or denial record and evidence of when it was received, where available. Keep later remittances separately. Record open-negotiation notices, correspondence, delivery records, and any existing dispute reference without assuming the newest remittance resets a deadline.
CMS lists a complete explanation of benefits, claim numbers, and service details among the information to have ready for federal IDR. Use its current process overview alongside the documents for the actual case.
What else should go in the file?
- Coverage and plan: available plan documents and information needed to determine the applicable payment-dispute route.
- Service circumstances: records that explain where and how the service was furnished.
- Authority: the provider’s authorization and relevant service or data-sharing agreements.
- Prior action: negotiation, appeal, settlement, or dispute records so the reviewer can see what has already been tried.
For eligibility, jurisdiction, and current fee guidance, see IDR Answers. This checklist organizes a handoff; it is not a regulatory filing checklist or Clearest import specification.
A reusable handoff checklist
Assign an owner to each row. Use “missing” or “not confirmed” when the evidence is unavailable, rather than guessing a value.
| Record to preserve | Typical source | Suggested owner |
|---|---|---|
| Claim and line identifiers | Submitted claim and remittance | Billing team |
| Provider, payer, and service details | Claim and practice records | Billing team / practice |
| Initial payment or denial and receipt evidence | ERA, EOB, notice, portal or delivery record | Notice recipient |
| Adjustment and remark codes | Original ERA or EOB | Payment posting team |
| Plan and service circumstances | Coverage and encounter records | Practice / eligibility reviewer |
| Negotiation and prior dispute activity | Notices, correspondence, dispute record | Existing dispute owner |
| Authorization and open questions | Executed agreements and exception log | Partnership lead |
Download a blank document inventory
Download the blank handoff worksheet (CSV)
Use one row for each document or missing record group. Record its version, secure source location, completeness, unresolved question, and owner. Link rows with an internal case or item reference without patient identifiers. Keep the original records in your approved system and leave missing facts unresolved until someone verifies them.
The file contains headers only. It is a document inventory, not a Clearest import format or an eligibility decision. Keep patient names, dates of birth, member numbers, and clinical details out of the worksheet. Agree on permissions and the secure channel before transferring any underlying claim documents.
A corrected remittance and a missing plan record
This invented example follows one internal reference, DEMO-01. It shows how a billing team and a receiving reviewer could organize a handoff. The labels and tasks below are suggested operating conventions, not a description of Clearest’s systems or a promised turnaround.
| What arrives | What is recorded | Owner and next action |
|---|---|---|
| Claim packet and ERA version 1 | DEMO-01, the source-document versions, and a transfer receipt. Handoff status: received. | Receiving contact checks the inventory against the agreed scope and permission. |
| Corrected ERA version 2 | Version 2 changes one line’s payment. Retain both versions and identify the affected line rather than overwriting version 1. | Payment posting owner checks the correction and updates the payment history. Dispute reviewer checks whether other case facts need review. |
| Plan type is still unconfirmed | Open question: which plan covers the service? Record the missing evidence and mark the handoff awaiting information. | Practice or billing contact requests the available plan record or written clarification. Eligibility reviewer checks the answer. |
| Clarification and updated inventory | The reviewer records what was resolved and any remaining unknowns. Accepted for review means only that the agreed review can proceed. | Receiving reviewer confirms the scope of acceptance; the person reviewing the dispute route records that separate conclusion. |
| A later filing, if authorized and appropriate | Use a filed or submitted label only with the actual submission record and reference. The transfer receipt is not filing evidence. | Filing owner retains the confirmation and continues monitoring requests and notices. |
For a missing record, return a specific question and the affected reference to its owner. For a correction, say which version changed and what needs rechecking. A new remittance does not, by itself, prove that a filing clock restarted; the person responsible for deadlines must assess the actual documents and current instructions.
CMS’s disputing-party guidance identifies plan information, complete payment records, correct contacts, and redaction among the preparation issues to check. Read the onboarding status definitions when agreeing on your team’s labels.
Example and worksheet added ; CMS document and communication sources checked for these additions on that date.
Check the package before transfer
Look for duplicate claim lines, reversals, missing pages, unreadable documents, and mismatched identifiers. Keep source files with the working record so another person can reproduce the review. Before sending patient information, check that the recipient is authorized and that you are using the agreed secure transfer method.
Ask the receiving team what arrived and what is still missing. A file can be received without being accepted for review, found eligible, or filed. Use a separate status for each step so your team knows where the claim stands.
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