Calling Script
Hi, I am (Pseudo
Name) calling from provider office… Checking on claim status…
Courtesy Greet
·
How do you do today? (at beginning of the call)
·
Hope you have a very good rest of the day… (at end of the
call)
The NATO Phonetic Alphabet
Letter
|
Phonic Word
|
Pronunciation
|
A
|
Alpha
|
AL FAH
|
B
|
Bravo
|
BRAH VOH
|
C
|
Charlie
|
CHAR LEE
|
D
|
Delta
|
DEL TAH
|
E
|
Echo
|
ECK OH
|
F
|
Foxtrot
|
FOKS TROT
|
G
|
Golf
|
GOLF
|
H
|
Hotel
|
HO TELL
|
I
|
India
|
IN DEE AH
|
J
|
Juliet
|
JEW LEE ETT
|
K
|
Kilo
|
KEY LOH
|
L
|
Lima
|
LEE MAH
|
M
|
Mike
|
MIKE
|
N
|
November
|
NO VEM BER
|
O
|
Oscar
|
OSS CAH
|
P
|
Papa
|
PAH PAH
|
Q
|
Quebec
|
KEH BECK
|
R
|
Romeo
|
ROW ME OH
|
S
|
Sierra
|
SEE AIR RAH
|
T
|
Tango
|
TANG GO
|
U
|
Uniform
|
YOU NEE FORM
|
V
|
Victor
|
VIK TAH
|
W
|
Whiskey
|
WISS KEY
|
X
|
X-ray
|
ECKS RAY
|
Y
|
Yankee
|
YANG KEY
|
Z
|
Zulu
|
ZOO LOO
|
Contents
1.
Overview…………………………………………………………………….5
2.
SIPOC………………………………………………………………………..6
3.
Procedures…………….……………………………………………………7
3.1 Claim in Process...…………………………………………………………7
3.2 Claim not on
file…………………………………………………………….7
3.3 Claim paid…………………………………………………………………...8
a. Claim paid
and the check is cashed………………………………...8
b. Claim paid more than 30days, paid
to correct address and the check
is not cashed……………………………………………….8
c. Claim paid to incorrect address……………………………………...9
d. Claim paid to patient……………………………………………………9
3.4 Claim processed towards deductible………………………….………..9
3.5 Claim denied for Eligibility……………………………………….……….10
3.6 Claim denied for Timely filing…………………………………….….......10
3.7 Claim denied as duplicate………………………………………….……..11
3.8 Claim pended for additional information………………………….…....11
3.9 Claim denied for non-covered service………………………………….12
3.10 Claim denied for primary EOB…………………………………………...13
3.11 Claim denied for Capitation……………………………………………....13
3.12 Claim denied for Billing/Coding error…………………………………..13
3.13 Claim denied for Authorization…………………………………………..14
3.14 Claim denied for Referral………………………………………………….15
3.15 Claim denied for Inclusive/bundle/Global/
Exclusive.........................15
1.
Overview
In medical
billing, AR stands for Accounts Receivable. Accounts receivable are the claims
that are unpaid by insurance companies or patients. An A/R caller is a person
who calls insurance companies about unpaid claims and tries to resolve the
reason the claim is unpaid. The AR calling team and AR Analysts work
hand-in-hand, and make sure the claims get paid. The coordination and
cooperation between these two departments benefits the practice by quickly
receiving payments. This is one of the most vital functions in Medical Billing.
The AR calling team Insurance does calling.
1. Insurance Calling
AR caller reviews the work-order given by
the AR Analyst and starts calling the insurance carriers to check on the status
of the claims filed with them. If the claim has been processed, AR callers get
the payment information. If the claim is denied, AR callers find the reason for
denial and see whether they can fix the denial while they are on the call with
the Insurance Carrier. If that is not viable option, the caller will note the
reason for the denial and pass it on to the AR analyst to fix the Denial. In
short, the caller contacts the insurer, gets the data on all the claims given
in the work order, and reports back to the AR Analyst to make sure necessary
action is taken on each claim.
2.
SIPOC
SUPPLIER
|
AR Analyst Team
|
INPUT
|
Aging claims, Denied claims, Missing info
request
|
PROCESS
|
Getting
claim status from insurance company over phone.
|
OUTPUT
|
Requested information will be provided to AR
analyst for further action.
|
3.
Procedures
3.1
Claim in Process
·
Claim received date
·
Processing time
·
Claim #
·
Ref #
3.2
Claim not on file
·
Effective date of coverage
·
Verify payer id/claim mailing
address/fax # with Attention
·
Verify id # and group #
·
Timely filing limit
·
Ref #
3.3
Claim paid
·
Claim processed date
·
Allowed amount, Paid amount,
Patient responsibility, Write off
·
Check/EFT date
·
Check # or EFT #
·
Check amount ( Single or bulk )
·
Check issued and cashed date
·
Pay to address
·
Need to request EOB only if the
check is cashed.
·
Ref #
Action:
a.
Claim
paid and the check is cashed
1. Request the EOB
and duplicate check copy thru fax (If paid date is more than 45 days from
current date).
b.
Claim
paid more than 30days, paid to correct address and the check is not cashed
1. Verify the pay to
address
2.
If the check was sent to correct address and the check was
not cashed after 45days then request for stop payment, request to reissue a new
check.
3.
If the check was sent to correct address and insurance
doesn’t know the cashed information after 30days then initiate a check tracer.
c.
Claim
paid to incorrect address
1. If the check was
issued to incorrect address verify the provider address with their database
2. If insurance has
different address then get the procedure to change the provider address and
send the necessary document.
3. If the insurance
has the correct address and the check was sent to different address request rep
to reissue the check to correct address.
d.
Claim
paid to patient
1. Check with
insurance as to why the claim was paid to patient.
·
Claim was paid to patient due to provider non par.
·
Claim was paid to patient since patient did not sign the AOB
(Assignment of Benefits).
2.
Get the paid details, including the check information.
3.4
Claim Processed towards
deductible
·
Processed date
·
Check how the claim was
processed ( in-network or out of network)
·
Annual deductible amount with
the balance
·
Request EOB
·
Claim #
·
Ref #
Action:
1.
Get the complete split up
details and request for copy of EOB thru fax.
3.5
Claim denied for Eligibility
·
Claim denial date
·
Effective and termination date
of coverage
·
Check whether the patient has an active coverage
with some other plan
·
Claim #
·
Request the EOB
·
Ref #
3.6
Claim denied for timely filing
·
Denial date
·
TFL
·
Claim #
·
Appeal address and appeal limit
·
EOB
·
Ref #
3.7
Claim denied as duplicate
·
Denial date
·
Status of original claim (
proceed further )
·
Claim #
·
EOB.
·
Ref #
Action:
1.
If we billed the claim twice
check the status for original claim.
2.
Please verify whether it is
corrected claim if yes request insurance to reprocess the claim.
3.
We submitted the claim as
corrected claim however insurance didn’t receive as “corrected claim”.
4.
If another provider billed for
same service and it was paid to different provider then get the appeal address
and appeal limit.
5.
If this is a duplicate charges entry
in billing software
3.8
Claim pended for additional
information
·
Claim processed date
·
What information is exactly
required and from whom ( Patient/provider) it required.
·
TFL to send the requested
information
·
Address/fax #
·
Claim #
·
EOB
·
Ref #
3.9
Claim denied for non-covered
service
·
Denial Date
·
Claim # and ref #
·
EOB
1.
Claim can be denied for non
covered charges under the below categories
a.
Patient plan –
i. DX not covered
ii. CPT not covered
iii. Patient seen out of network providers
iv. POS not covered
v. Patient plan covers only specific type of services.
b.
Provider contract –
i. Provider specialty doesn’t cover this procedure
ii. This has to be performed in
specific lab
iii. Globally non covered charges
3.10
Claim denied for primary EOB
·
Denial Date
·
Primary insurance name
·
TFL to send claim with primary
EOB
·
Payer id, Claim mailing
address, faxes # with attn.
·
Claim # and Ref #.
3.12
Claim denied for Billing/Coding
error
·
Denial Date
·
EOB
·
TFL to send corrected claim
·
Claim mailing address, payer
id, and fax #with attn.
·
Claim # and ref#.
Action:
1.
The following denials will come
under billing/coding error.
Ø Coding related issue
o
CPT and modifier combination invalid
o
CPT/Dx not valid for DOS/
incorrect
o
4or 5th digit Dx is
missing
o
CPT/Dx inconsistent with
patient gender or age
o
POS inconsistent with CPT
Ø Billing related issue
o
Member id # is invalid
o
Patient name, DOB and id #
mismatch
o
DOS entered in not valid
o
Patient relationship is
incorrect
o
POS inconsistent with CPT
3.13
Claim denied for Authorization
·
Denial Date
·
Appeal address/ Fax with Attn
·
Claim # and ref #
a.
For an in-network physician
authorization is not required. Explain this to rep and reprocess the claim.
b.
Authorization is required only
if the provider is non par.
3.14
Claim denied for Referral
·
Denial Date
·
TFL to send corrected claim/
appeal
·
Address/fax # to send corrected
claim/ appeal
·
PCP name and phone #
·
Claim # and ref #
·
EOB
Action:
1.
Check with insurance whether it
is HMO plan
2.
Forward to missing information
– Tickler date 30days
3.15
Claim denied for
Inclusive/bundle/Global/Exclusive
·
Denial Date
·
Check with insurance can we
resubmit with appropriate modifier or can we appeal.
·
TFL to send corrected claim/
appeal
·
Address/fax # to send corrected
claim/ appeal
·
Included CPT with DOS/global
period
·
Claim # and ref #
·
EOB
------------------------------------------END----------------------------------
Comments
Post a Comment