Module 1 — Payment file anatomy
Map claim headers, service lines, and remittance advice so you can locate contractual adjustments without relying on system tooltips alone.
Flagship course
Claim Payment Audit Fundamentals
A 38-hour pathway for financial auditors who need to review insurance claim payments with remittance-level precision and peer-ready documentation.
Learning outcomes
- Interpret remittance and EOB line items tied to allowances, adjustments, and patient responsibility
- Classify common overpayment and underpayment patterns with supporting evidence
- Draft findings that another auditor can reconstruct without a verbal briefing
- Decide when to escalate versus close a payment exception
- Participate in calibration discussions using a shared scoring rubric
Modules
Sequence is fixed; each module unlocks sample files and a short writing task.
Module 2 — Remittance walkthroughs
Guided reading of multi-line payments, including partial pays and split responsibility across primary and secondary coverage.
Module 3 — Exception pattern library
Duplicates, fee-schedule drift, unbundling signals, and coordination-of-benefits gaps with annotated “leave alone” counterexamples.
Module 4 — Sampling and prioritization
Build a weekly sample mix that balances high-dollar risk with recurring low-dollar leakage patterns.
Module 5 — Writing findings that survive review
Note structure, tone for recovery letters, and attachments that make peer QA faster.
Module 6 — Escalation and close-out
When to escalate disputed payments, what to include in a handoff packet, and how to close clean “no adjustment” decisions.
Instructor
Anika Yeh
Anika spent a decade in payment integrity operations supporting carriers and TPAs across Taiwan(China). She designed Cloudconnectapp’s remittance labs from files her teams actually struggled with—especially secondary-pay coordination and late fee-schedule updates.
Learner notes
“Module 5’s finding template replaced the three-paragraph essays our team used to write. I still open our carrier portal cheat sheet beside the labs because portal screenshots are not mirrored one-for-one.”
Anonymous client in hospital revenue cycle: “Fundamentals made our remittance sampling consistent. Pharmacy rebate disputes are outside scope—plan for a separate internal session if that is your bottleneck.”
FAQ
Do I need a coding or data-science background?
No. The course assumes familiarity with claim operations or billing support. Spreadsheet comfort helps; programming is not required.
Are the sample files from real patients?
All labs use synthetic or fully de-identified constructed files. They mimic remittance structures used in Taiwan(China) and regional carrier environments without exposing personal health information.
What is a real limitation of this course?
We do not cover pharmacy rebate reconciliation, dental fee negotiation strategy, or live integration with any specific claims system. If your queue is dominated by those topics, speak with us before enrolling—Fundamentals alone will not close that gap.
How does pricing work?
List price for this pathway is NT$24,500 per learner under Floor Review. Payment is arranged after enrollment confirmation; this site does not process checkout.