AR MANUAL, ISSUES AND ACTIONS

AR MANUAL

ISSUES AND ACTIONS

Claim not on file

n  Claims mailing address

n  Fax #

n  Whose attention the claim has to be faxed

n  Effective date

n  Timely filing period

n  Verify id and group #.

n  May I have the claims mailing address?

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

n  Is patient eligible for the DOS?

n  May I have the filing limit for this claim?

Claim in process

n  Date of receipt of the claim

n  Processing time.

n  Can I have the date on which the claim was received?

n  How long would that take to process this claim?

Claim forwarded to the payer from the pricing center

n  Date of forwarding of claim to the payer

n  Payer phone number.

n  Could you please tell me the date on which the claim was forwarded to the payer?

n  Can I know the phone number for the payer please?

Claim paid

n  Check #

n  Check date

n  Paid amount

n  Allowed amount

n  Patient's responsibility

n  Write off

n  Pay to address

n  Cashed date

n  Could you please tell me the check # and check date?

n  How much was the allowed amount for the claim

n  Can you please tell me how much was paid for this DOS?

n  Are there any write off on this claim?

n  What would be patient’s responsibility?

n  Can you verify the pay to address for me please?

n  Was the check cashed?

Claim paid to wrong address

n  Verify pay to address

n  Telephone appeal to update

n  W9 form

n  Cancelled check copy if cashed

n  If not, request for stop payment and reissue the check.

n  Could you verify the pay to address for me please?

n  Can you go ahead and update your records if I give you the correct pay to address for the provider over phone?

n  Could you please give me the fax # and can I go ahead and fax W9 form to your attention?

n  Please fax us a copy of the cancelled check if the check has already been cashed

n  Could you please put a stop payment for this check and reissue the check to the correct address?

Claim denied for untimely filing

n  Date of denial

n  Re-filing and appealing address

n  Verify timely filing limit

n  Fax number.

n May I have the denial date and the filing limit for this claim?

n  Can I have the address where I need to appeal for this claim?

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

Claim denied for eligibility

n  Date of denial

n  Effective/ termination date of coverage

n  EOB request

n May I have the denial date for this claim?

n May I have the effective / termination date of patients policy?

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

Claim denied for non covered services

n  Date of denial

n  Details of the non covered service

n  Check if patient can be billed

n  EOB request.

n  May I have the denial date for this claim?

n  Could you please tell me the services that are not covered under this plan?

n   Can we go ahead and bill the patient for this claim?

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

Claim denied for EOB from the primary insurance

n  Date of denial

n  Information on primary insurance if the rep has with their system

n  Fax number

n  May I have the date this claim was denied?

n  Would you be able to re-process this claim if I were to fax you the Primary EOB?

Claim denied for cob

n  Date of denial

n  Information of the other insurance if they have on their file

n  EOB request

n  May I have the date this claim was denied?

n  Would you be able to tell me if the patient has any other Insurance?

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

Claim denied for capitation

n  Date of denial

n  If possible date of  Capitated contract

n  Request for EOB

n  May I have the date this claim was denied?

n  May I have the date of capitated contract?

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

Claim denied for authorization number

n  Date of denial

n  Check if there is any auth in the software mentioned for the dos

n  Check if they have an auth on file for any hospital claim for the same dos

n  Fax number

n  EOB request.

n   May I have the date this claim was denied?

n   Could you please tell me if you see any authorization # for the same DOS for the hospital claim?

n   I have a authorization # in the system, could you re-process the claim if I give this number to you now?

n  Would you be able to re-process this claim if I were to fax you the claim with authorization number?

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

Claim denied for referral

n  Date of denial

n  Check if there is any referral on the software mentioned for the dos

n  Check if provider is participating

n  Fax number

n  EOB request.

n  May I have the date this claim was denied?

n  I have a referral # in the system, could you re-process the claim if I give this number to you now?

n  Would you be able to re-process this claim if I were to fax you the claim with referral number?

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

Claim denied as bundled/ incidental/ inclusive

n  Date of denial

n  Major procedure to which it has been bundled

n  Can we appeal with medical notes

n  Fax number

n  EOB request.

n  May I have the date this claim was denied?

n  Could you please tell me to which major procedure the claim has been bundled to?

n  Can I have the address where I need to appeal for this claim?

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

Claim denied for referring physician

n  Date of denial

n  Ask if provider is the PCP

n  If not ask for PCP’s name and phone number

n  Insurance fax number

n  EOB request.

n   May I have the date this claim was denied?

n   Would you be able to reprocess this claim if I give you the referring physician’s name and UPIN #?

n  Can I have your fax number?

Claim denied for incorrect provider

n  Date of denial

n  Correct provider info

n  Fax number

n  EOB request.

n  May I have the date this claim was denied?

n  I have the correct provider # in the system, could you re-process the claim if I give you this information?

n  Can I have your fax number please?

Claim denied as primary paid maximum

n  Date of denial

n  Allowed amount

n  Verify the primary payment details

n  EOB request.

n   May I have the date this claim was denied?

n   May I know the allowed amount for this claim?

n   Could you please tell me how much did the primary paid on this claim?

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

Claim denied for wrong diagnosis

n  Date of denial

n  Correct diagnosis code

n  Fax number

n  EOB request.

n  May I have the date this claim was denied?

n  Could you please tell me which is correct diagnosis for this procedure?

n  Can I have your fax number please?

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

Claim denied for modifier

n  Date of denial

n  Correct modifier

n  Ask for fax number

n  EOB request

n  May I have the date this claim was denied?

n  Could you please tell me which is correct modifier for this procedure?

n  Can I have your fax number please?

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

Claim denied for pre-existing condition

n  Date of denial

n  Pre-existing condition

n  EOB request

n  May I have the date this claim was denied?

n  Could you tell me the condition that was classified as pre-existing for this patient?

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

Claim denied as not medically necessary

n  Date of denial

n  Appeal with medical notes

n  Fax number

n  EOB request

n  May I have the date this claim was denied?

n  Can I go ahead and send the appeal with medical notes?

n  Can I have your fax number please?

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

Claim denied for untimely follow up

n  Appealing address

n  Verify timely follow up time

n  Fax number

n  May I have the date this claim was denied?

n  Can I go ahead and send the appeal with proof of timely follow up?

n  Could you tell me the follow up time for this claim?

n  Can I have your fax number please?

Claim denied as duplicate

n  Date of denial

n  Primary dos to which the claim is denied as duplicate

n  Appeal with medical notes

n  Fax number.

n  May I have the date this claim was denied?

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

n  Can I go ahead and send the appeal with medical notes?

n   Can I have your fax number please?

Claim denied as Offset

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

n  May I have the date this claim was denied?

n  Could you give the details of the DOS offset to?

n  How much was offset to?

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

Claim pending for additional information

n  Details of the information required

n  Fax number

n  Could you tell me the information required to process this claim?

n  May I have your fax number please?

Claim processed towards patient's deductible

n  Processing date

n  Provider in or out of network

n  Break up of the benefits

n  EOB request.

n  May I know the date on which this claims was processed?

n  Is the provider out of network?

n  Could you please tell me how much was processed towards the deductible?

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

Claim paid to patient

n  Check if provider is participating

n  Payment details

n  EOB request.

n  May I know when was the claim paid to patient?

n  Can I know how much was paid to the patient?

n  Is the provider participating? Could you fax / mail me a copy of the EOB?