AR Manual

AR MANUAL

ISSUES AND ACTIONS

Claim not on file

• Claims mailing address
• Fax #
• Whose attention the claim has to be faxed
• Effective date
• Timely filing period
• Verify id and group #.
• May I have the claims mailing address?
• Could you please give me the fax # and can I go ahead and fax it your attention?
• Is patient eligible for the DOS?
• May I have the filing limit for this claim?

Claim in process

• Date of receipt of the claim
• Processing time.
• Can I have the date on which the claim was received?
• How long would that take to process this claim?

Claim forwarded to the payer from the pricing center

• Date of forwarding of claim to the payer
• Payer phone number.
• Could you please tell me the date on which the claim was forwarded to the payer?
• Can I know the phone number for the payer please?

Claim paid

• Check #
• Check date
• Paid amount
• Allowed amount
• Patient's responsibility
• Write off
• Pay to address
• Cashed date
• Could you please tell me the check # and check date?
• How much was the allowed amount for the claim
• Can you please tell me how much was paid for this DOS?
• Are there any write off on this claim?
• What would be patient’s responsibility?
• Can you verify the pay to address for me please?
• Was the check cashed?

Claim paid to wrong address

• Verify pay to address
• Telephone appeal to update
• W9 form
• Cancelled check copy if cashed
• If not, request for stop payment and reissue the check.
• Could you verify the pay to address for me please?
• Can you go ahead and update your records if I give you the correct pay to address for the provider over phone?
• Could you please give me the fax # and can I go ahead and fax W9 form to your attention?
• Please fax us a copy of the cancelled check if the check has already been cashed
• Could you please put a stop payment for this check and reissue the check to the correct address?

Claim denied for untimely filing

• Date of denial
• Re-filing and appealing address
• Verify timely filing limit
• Fax number.

• May I have the denial date and the filing limit for this claim?
• Can I have the address where I need to appeal for this claim?

• Could you please give me the fax # and can I go ahead and fax it to your attention?

Claim denied for eligibility

• Date of denial
• Effective/ termination date of coverage
• EOB request

• May I have the denial date for this claim?
• May I have the effective / termination date of patients policy?

• Could you please fax / mail me a copy of the EOB

Claim denied for non covered services

• Date of denial
• Details of the non covered service
• Check if patient can be billed
• EOB request.

• May I have the denial date for this claim?
• Could you please tell me the services that are not covered under this plan?
• Can we go ahead and bill the patient for this claim?

• Can I get a copy of this EOB faxed / mailed to me please?

Claim denied for EOB from the primary insurance

• Date of denial
• Information on primary insurance if the rep has with their system
• Fax number
• May I have the date this claim was denied?
• Would you be able to re-process this claim if I were to fax you the Primary EOB?

Claim denied for cob

• Date of denial
• Information of the other insurance if they have on their file
• EOB request
• May I have the date this claim was denied?
• Would you be able to tell me if the patient has any other Insurance?
• Could you fax / mail me a copy of the EOB?

Claim denied for capitation

• Date of denial
• If possible date of Capitated contract
• Request for EOB

• May I have the date this claim was denied?
• May I have the date of capitated contract?

• Could you fax / mail me a copy of the EOB?

Claim denied for authorization number

• Date of denial
• Check if there is any auth in the software mentioned for the dos
• Check if they have an auth on file for any hospital claim for the same dos
• Fax number
• EOB request.

• May I have the date this claim was denied?
• Could you please tell me if you see any authorization # for the same DOS for the hospital claim?
• I have a authorization # in the system, could you re-process the claim if I give this number to you now?
• Would you be able to re-process this claim if I were to fax you the claim with authorization number?

• Could you fax / mail me a copy of the EOB?

Claim denied for referral

• Date of denial
• Check if there is any referral on the software mentioned for the dos
• Check if provider is participating
• Fax number
• EOB request.
• May I have the date this claim was denied?
• I have a referral # in the system, could you re-process the claim if I give this number to you now?
• Would you be able to re-process this claim if I were to fax you the claim with referral number?
• Could you fax / mail me a copy of the EOB?

Claim denied as bundled/ incidental/ inclusive

• Date of denial
• Major procedure to which it has been bundled
• Can we appeal with medical notes
• Fax number
• EOB request.
• May I have the date this claim was denied?
• Could you please tell me to which major procedure the claim has been bundled to?
• Can I have the address where I need to appeal for this claim?
• Could you please give me the fax # and can I go ahead and fax it to your attention?

Claim denied for referring physician

• Date of denial
• Ask if provider is the PCP
• If not ask for PCP’s name and phone number
• Insurance fax number
• EOB request.

• May I have the date this claim was denied?
• Would you be able to reprocess this claim if I give you the referring physician’s name and UPIN #?

• Can I have your fax number?

Claim denied for incorrect provider

• Date of denial
• Correct provider info
• Fax number
• EOB request.

• May I have the date this claim was denied?
• I have the correct provider # in the system, could you re-process the claim if I give you this information?

• Can I have your fax number please?

Claim denied as primary paid maximum

• Date of denial
• Allowed amount
• Verify the primary payment details
• EOB request.

• May I have the date this claim was denied?
• May I know the allowed amount for this claim?
• Could you please tell me how much did the primary paid on this claim?

• Could you fax / mail me a copy of the EOB?

Claim denied for wrong diagnosis

• Date of denial
• Correct diagnosis code
• Fax number
• EOB request.

• May I have the date this claim was denied?
• Could you please tell me which is correct diagnosis for this procedure?
• Can I have your fax number please?

• Could you fax / mail me a copy of the EOB?

Claim denied for modifier

• Date of denial
• Correct modifier
• Ask for fax number
• EOB request
• May I have the date this claim was denied?
• Could you please tell me which is correct modifier for this procedure?
• Can I have your fax number please?
• Could you fax / mail me a copy of the EOB?

Claim denied for pre-existing condition

• Date of denial
• Pre-existing condition
• EOB request
• May I have the date this claim was denied?
• Could you tell me the condition that was classified as pre-existing for this patient?
• Could you fax / mail me a copy of the EOB?

Claim denied as not medically necessary

• Date of denial
• Appeal with medical notes
• Fax number
• EOB request
• May I have the date this claim was denied?
• Can I go ahead and send the appeal with medical notes?
• Can I have your fax number please?
• Could you fax / mail me a copy of the EOB?

Claim denied for untimely follow up

• Appealing address
• Verify timely follow up time
• Fax number
• May I have the date this claim was denied?
• Can I go ahead and send the appeal with proof of timely follow up?
• Could you tell me the follow up time for this claim?
• Can I have your fax number please?

Claim denied as duplicate

• Date of denial
• Primary dos to which the claim is denied as duplicate
• Appeal with medical notes
• Fax number.

• May I have the date this claim was denied?

• Can I have the details of the primary procedure to which claim is duplicated?

• Can I go ahead and send the appeal with medical notes?
• Can I have your fax number please?

Claim denied as Offset

• Date of denial, Offset dos details, Amount offset, EOB request

• May I have the date this claim was denied?

• Could you give the details of the DOS offset to?
• How much was offset to?

• Could you fax / mail me a copy of the EOB?

Claim pending for additional information

• Details of the information required
• Fax number
• Could you tell me the information required to process this claim?
• May I have your fax number please?

Claim processed towards patient's deductible

• Processing date
• Provider in or out of network
• Break up of the benefits
• EOB request.

• May I know the date on which this claims was processed?
• Is the provider out of network?
• Could you please tell me how much was processed towards the deductible?

• Could you fax / mail me a copy of the EOB?

Claim paid to patient

• Check if provider is participating
• Payment details
• EOB request.

• May I know when was the claim paid to patient?
• Can I know how much was paid to the patient?
• Is the provider participating? Could you fax / mail me a copy of the EOB?