1.Patient Not On File
Title
| Patient not on file |
Scenerio
1. Check with patients name, date of birth, first name, last name, SSN #
2. If the insurance rep unable to pull then the patient doesn’t have a plan with this
3. That patient would have different insurance
4.Claim#
5. Call reference #
Action
Call patient to find active/correct insurance details
2.Claim Not On File
Title
Claim not on file
Scenerio
1. Whether the Patient is eligible for the date of service
2. Check the claims mailing address, whether the claim sent to the correct address
3. Timely filing limit to resubmit
4.Claim#
5. Call reference #
Action
1.If the patient eligible then get the correct mailing address/payor id and resubmit
2. If the patient is not eligible then call the patient to find active insurance
3.Claim in Process
Title
Claim in Process
Scenerio
1. What is the received date of the claim
2. Check with a normal claim processing time of the payer
3. If it is within 30 days from the day you are calling then close the call with Claim # and Call reference #
4. If it is more than 30 days get the delay reason of claim processing
5. Claim #
6.Call reference #
Action
1.If the claim received recently(below 30days) please be allow some more time
2.If the claim received (over 30days) ask rep to escalate to process soon
4.Claim Processed Towards Deductible
Title
Claim processed towards
deductible
Scenerio
Claim processed towards deductible Less than 30 days
1.Processed Date
2. What is the Deductible amount allowed for this claim
3. Annual Deductible amount
4. Family or Individual Deductible
5. How much met by the patient
6. If it is less than 30 days from the date of calling
7. Claim #
8. Call reference #
Claim processed towards deductible More than 30 days
1.Processed Date
2. What is the Deductible amount allowed for this claim
3. Annual Deductible amount
4. Family or Individual Deductible
5. How much met by the patient
6.Ask to which address the initial EOB was sent
7. Request for a copy of EOB to the pay to address
8. Claim#
9. Call reference #
Action
1.Once EOB received then, check patient has a secondary payer if the secondary payer is available check the eligibility of the secondary payer and submit with this EOB
2. If no secondary payer then bill the patient with a patient statement
5.Claim Paid Recently (below 30days)
Title
Paid claim within 30 days
Scenerio
1. Allowed Amount
2. Paid Amount
3. Patient Responsibility and the balance of providers adjustment amount
4. Paid through Check or EFT and get the check or EFT #
5. Single or Bulk
6. To which address the ‘EOB or remittance initiated to
7. Claim #
8. Call reference #
Action
Allow some time to receive the EOB once EOB received the send to the posting team
6.Claim Paid Recently (over 30days)
Title
Paid claim more than 30 days
Scenerio
1. Allowed Amount
2. Paid Amount
3. Patient Responsibility and the balance of providers adjustment amount
4. Paid through Check or EFT and get the check or EFT #
5. Single or Bulk
6.Cash date?
7.No cash date then request check trace
6. To which address the EOB or remittance initiated to
7. Request for a copy of paid EOB or remittance to the Pay to Address
8. Claim #
9. Cail reference #
Action
1.Once the check trace initiated wait till the time given by the rep and then call back to find out where the check sent to.
2. If check sent to a different address ask to reissue a new check
7.Claim Denied for Medical Records
Title
Claim Denied for Medical
Records
Scenerio
1. What medical record is required
2. If the rep doesn’t have a specification of the record, mention the same in the claim
3. Check in the system whether any records available or already sent to the payer
4. If not get the mailing address where the records need to be sent
5. Timely filing limit
6. Claim#
7. Call reference#
Action
1.If medical records found in the system then submit it to the payer
2.If no medical records found then escalate to the client to attach the medical records once medical records attached then submit it to the payer
8.Claim Denied for Pre-existing Information
Title
Claim denied for Pre-existing
information
Scenerio
1. Claim will be denied for additional information
2. What information is required
3. If the additional information is pre-existing Information
4:Then ask From whom the information is required
5. For both patient and provider ask how many letters were sent
6. When was the last letter sent
7. Address to update the information with the timely filing limit
8.Get the waiting period
9. Claim#
10. Call reference#
Action
1.If DOS lies within the waiting period then bill the claim to the patient.
2. If DOS not lies between the waiting period then ask the rep to reprocess
3.Do not bill the claim to secondary or consecutive payer since they are not going to process the claim.
9. Additional Information from the Patient
Title
Additional
Information from the Patient
Scenerio
1. What information is required from the patient
2.If COB need to update the ask how many Letters was sent to the patient
3. When was the last letter sent to the patient
4. Mailing Address to update the information
5. Timely filing limit
6. Claim#
7. Call reference#
Action
1.If the letter was sent to the patient has not crossed 30 days allow some more time.
2. If the letter was sent has crossed 30 days then bill the claim to the patient.
3.If claim denied for COB update then check patient payment history if the payment on nearby DOS received from any other insurance as a primary then check the eligibility of that insurance and bill the claim to that insurance.
10. Claim denied for Invalid CPT
Title
Claim denied for Invalid CPT
Scenerio
1. Denied date
2. Check in the billing summary and see whether the denied CPT is paid
before in any date of service by the same payer
3. If it is paid cross verify with the rep that in the previous date of service the
same code got paid.
4. If it is not pald, get the corrected claim mailing address with the timely
filing limit
5. Claim#
6. Call reference#
Action
1.Check payment history, If the same CPT was already paid on another DOS then verify with the rep and reprocess
2.If no payment found previously on this CPT code then send it to the coding team to find the correct CPT once the coding team updated with the new CPT code then resubmit to the payer
