December 10, 2015

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Prompt Payment Appeals: Saying "What is Taking So Long" in Optimal Wording

While some initial reports on ICD-10 claim processing have been favorable, many providers are experiencing payment delays and other revenue cycle challenges related to the coding transition.

Both CMS and RelayHealth issued claims processing reports reflecting little change in denial rate metrics. According to the CMS report, denials for October, 2015 were about ten percent of submitted claims. . . . .

Keep reading this article. New Content

To assist with prompt payment escalation and remittance transparency under ICD-10, we have developed the following document available in the Download Library:

ICD-10 Prompt Payment and ERA Clarification Guidance (new content!)

We also have state-specific letters citing state prompt payment regulations for each state. Visit the Appeal Letter Repository to review these state-specific appeal letters. If your state has issued any prompt-payment guidance related to ICD-10, please let us know by emailing

We have also developed a number of follow-up letters for use during the ICD-10 transition. These letters would not necessarily be considered "appeal letters" since they primarily address a payers' lack of prompt processing and/or lack of ERA transparency. Appeals are only initiated when a clearly-worded denial has been received. Therefore, when using an inquiry letter to follow-up on unprocessed/unclear remittances, the appeal process restrictions on number of appeals should not be triggered.

Access the appeal letters at

Payer Spotlight: Medicaid - Performance Concerns Amidst Medicaid Population Growth

Medicaid is being closely monitored by CMS for ICD-10 compliance.

According to CMS's State Medicaid ICD-10 Readiness page, more than 70% of Medicaid is provided through managed care. CMS has ensured that each state is working with their Medicaid managed care organizations (MCOs) to ensure that they are ready to receive and process ICD-10 claims. Statesí general practices have included requiring the MCOs to attest to their readiness and/or share their own test results.

Medicaid organization are of particular concern under the transition due to historical performance on claims process. AthenaHealth's Payerview Report has outlined the following performance challenges specific to Medicaid historical claims data analysis:

  • Slowest to pay out. Compared with other payers, Medicaid is consistently the slowest in days in accounts receivable (DAR) between charges submitted and payment received.
  • Highest denial rates, least transparent. When claims get denied, itís important for payers to return them with Electronic Remittance Advice (ERA), including clear next steps and denial explanation. Unfortunately, Medicaid has the highest denial rate - and also the lowest ERA transparency.

For organization with a high Medicaid claim volume, be sure to track any updates issued through CMS specific to Medicaid organization. The website is and has state-by-state links to Medicaid ICD-10 Readiness updates.

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