Transactions and Recent Activity
Minimum number of recent notes you should review
Last 5 notes
This tag must be present to continue the L0–L1 review.
PESC_Proposed
Spreadsheet used to confirm whether a payer is supported for escalation.
PAT E2E Payer Matrix
Root cause category for “claim/appeal/records sent, no response.”
Payer Processing Delay
Document used to validate payer-specific delay timelines and operational action requirements.
PAT E2E Escalation Requirements – Client v Payer
If activity happened after proposal, the key question is whether this is still true.
The original defect/issue is still unresolved
Two places in R1D you can find the PESC_Proposed tag.
Top navigation bar or Tag Information section
Any account with this payer type is an auto-reject for Payer Accountability.
VA/Tricare (also Auto, Workers’ Comp, straight Medicare, straight Medicaid)
Root cause category for “auth on file/coding correct/timely filing denied in error.”
Erroneous Denial
You may accept if you’re within this many days of meeting the required delay timeframe.
5 days
Two R1D areas you should check for payments/recoups and remits
Financial Information → Insurance Payments and Claims & Remittances
If PESC_Proposed is present and another active PESC tag is also present, you do this.
Remove PESC_Proposed
Two R1D places you can use to identify/confirm the payer.
Patient Information or Eligibility & Benefits
Root cause category for “paid less than expected” or “erroneous recoupment.”
Contractual Underpayment
Proof of payer contact should typically be within the last:
30 days
If a payment posted after proposal, you should do this before deciding.
Confirm whether the payment resolves the defect (then accept/reject accordingly)
The area you check to see if tags were repeatedly added/removed (e.g., within the same week).
Tag History
If the payer is straight Medicare, the correct disposition is:
Reject
The number of Payer Defect root causes listed in the guide.
3 - Payer Processing Delay, Contractual Underpayments, Erroneous Denials
Whether approving or rejecting, this tag should be removed:
PESC_Proposed
The determination made when an account has no transactions or notes between proposed date and review date
If there are multiple PESC tags on an account, document it here
Tag Issues Log
The status determined when an account is a 2024 Aetna account with Sutter (Hint: M&C)
Reject
The kind of charges that should always be paid in the US
Emergency Room (ER)
Exact rejection note prefix example from the guide (one of them).
PESC Rejected: Payment Received (also acceptable: PESC Rejected: Payer Qualification(s) Not Met, PESC Rejected: Payer Promise to Pay Rec’d, PESC Rejected: New Denial/ADR Received)