Investigate the Entire
Account, Not Just the Code
Practice resolving realistic fictional billing accounts in a simulated AR environment. Reconcile money, review only the evidence you actually need, decide whether to transfer, adjust, bill, rebill, correct, follow up, or stop, and get detailed feedback on every decision.
Investigation Rules
Every scenario follows these core principles. Internalize them before you start.
One Account at a Time
Never carry data from another scenario into the current one.
Reconcile the Money
Billed − paid − adjustments − patient resp − transfers = expected balance.
EOB is Primary Evidence
Do not adjust without evidence supporting the amount and reason.
A Balance ≠ Adjust
Determine WHY the balance remains before recommending an action.
Resolve Before Escalating
Ask whether normal billing workflow can fix it before routing it elsewhere.
Policy Is Organization-Specific
Employer thresholds and routing rules are scenario policy — not universal billing law.
Practice Scenarios
Each scenario is a complete simulated account. Work one at a time — reconcile the money, review the evidence, and choose the correct action.
CO186 Residual Balance on ED Visit
A multi-line ED claim has a $990.00 remaining payer balance. Investigate whether this balance requires action or corresponds to a valid adjustment.
Partial Timely Filing Write-Off
A claim was rejected twice for incorrect DOB and not corrected before timely filing expired. A write-off was requested for $2,711.81 but only $1,724.71 was posted. Investigate the remaining balance.
Secondary Insurance Never Billed
Primary payer processed the claim and transferred $320.00 to patient responsibility. A secondary insurance plan is active but no secondary claim was ever generated.
Payment Recoupment Creates New Balance
A claim was originally paid and contractual adjustments posted. Later, a large payment reversal/recoupment appears and creates a new payer balance. No new denial supports an adjustment.
Procedure Code Invalid for Date of Service
A procedure line denies because the procedure code was retired and is no longer valid for the date of service. Investigate and determine the correct escalation path.
Final EOB Changes Patient Responsibility to Zero
Original payer processing placed $285.00 in patient responsibility. A later reprocessed/final EOB shows patient responsibility should be $0.00. The account still carries the old patient balance.
No-Authorization Denial: Appeal First or Write-Off?
A no-authorization denial has a small remaining balance. Prior notes suggest an appeal may have been sent, but the formal tracking history does not confirm it and appeal rights are now expired. Use organization policy to route the account correctly.
Medical Records Reconsideration Still Leaves One Line
Medical records were already submitted and the payer reprocessed the claim, but one $955.00 line remains unpaid with a documentation remark. Determine whether to adjust, resend everything, or submit the specific missing records.
Secondary Claim Accepted — Do Not Rebill
The primary payer assigned $942.00 to patient responsibility and a secondary plan is active. The secondary claim was accepted only a few days ago. Decide whether to rebill, transfer to patient, or wait.
EOB Adjustment vs Payment/Charge Mismatch
The EOB supports a $990.00 provider adjustment, but the billing system has a $39.87 charge difference and a related payment already posted. The current payer balance is $950.13. Decide whether to post the balance, post the full EOB adjustment, or escalate the posting mismatch.
Added Charges Require a Replacement Claim
An original inpatient Medicare claim already processed. Additional charges were added after adjudication, and no replacement claim exists. Decide whether to rebill the original claim or submit the correct replacement.
Secondary OA23 Already Processed
Primary processed the claim and the secondary already adjudicated the same balance with OA23. The account still carries the amount under primary. Decide whether to rebill secondary or finish the secondary workflow.
No Payer Response Does Not Mean Rebill
An updated claim was produced and accepted, but the payer has not adjudicated it yet. There is no rejection. Decide whether the lack of a response means another claim should be sent.
CO24 Medicare Advantage Coverage Is Missing From the Visit
Original Medicare denied the full claim CO24 because a Medicare Advantage plan was active. Eligibility verifies the plan, but it is not available on the visit. Decide what to do without changing insurance yourself.
Educational Simulation: All patient names, MRNs, claim numbers, and insurance details are fictional and created for educational purposes only. No real patient data is used. DenialPro provides educational claim investigation and workflow guidance. Final billing, coding, adjustment, appeal, and payer actions must follow your organization's policies, payer contracts, and applicable regulations.
Ready to Investigate?
Choose a scenario above and start investigating. Every decision gets detailed feedback.
Also check out the Denial Resolution Training Simulator