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 |
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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