Medical Billing and Coding Certification

As the healthcare and insurance industries require accuracy and compliance with complex regulations, medical billers and coders are held to these same standards. Certification is a way of showing your dedication and expertise. While you may not necessarily need a medical coding certification to get an entry-level job, you will find that your opportunities for career advancement multiply once you’ve achieved such a distinction. You’ll be more likely to demand a higher salary, earn a position of leadership, and perform different kinds of work.

Certifications are available for various professionals that work in the medical records and health information field. They’re also offered by a number of different organizations. As you plan your career goals, do your research to get the basic facts about certification and opportunities for specialization. Then consider a timeline for gathering the education, training, and experience that will help you pass the certification exam that’s right for you.

Explore Certification and Continuing Education

Important information about the types of certification available for medical billers and coders is explained in the following section.

AAPC certification

The most well-known agency that administers and oversees certifications for medical billers is The American Association of Professional Coders (AAPC). It also tracks required continuing education units through a system that records the knowledge you’ve gained from classes, conferences, seminars, and other educational opportunities on a variety of topics. The AAPC offers general certifications, as well as 21 specialty certifications.

General certifications: The main certifications are the Certified Professional Coder (CPC), Certified Professional Coder – Hospital Outpatient (CPC-H), and Certified Professional Coder – Payer (CPC-P).

Specialty-specific coding certifications: You can choose to focus on a particular area in the healthcare industry and pursue certification to demonstrate expertise in that area. These specialty certifications emphasize coding problems related to those fields, as well as professional requirements to work in these areas. You don’t necessarily need to acquire a general coding certification to obtain one of these specialty certifications (see the AAPC website for accurate and up-to-date information about specific requirements), but you will find that a variety of certifications make you more versatile and marketable to employers.

Use the following list to discover the wide variety of medical billing and coding jobs that are available across all sectors of the healthcare industry.

• Ambulatory Surgical Center (CASCC™): Also known as outpatient surgery, ambulatory surgical centers (or same-day surgery) perform medical procedures that do not require overnight stay. This specialization requires knowledge of surgical procedures. You’ll interpret notes provided by medical professionals and convert them into medical codes that accurately represent highly specific information. There are no prerequisites for this certification exam (other than AAPC membership,) which is designed to simulate the transcription of case notes.
• Anesthesia and Pain Management (CANPC™): Anesthesiologists administer drugs to patients for their symptoms or as part of their surgical procedures. You’ll be expected to know how to choose the right CPT codes for different procedures, as well as how to use modifiers for anesthesia cases. You’ll also be tested on determining time units and total units for cases that require anesthesia.
• Cardiology (CCC™): Heart health is a growing sector of the healthcare industry. Passing the examination for this certification demonstrates that you have a knowledge of cardiological surgical practices and equipment, such as stents and pacemakers. Because heart health is often related to other vascular procedures and has associated insurance regulations, this coding specialization presents unique challenges. You’ll be expected to know how to code for surgical procedures such as catheterization, placement of pacemakers, and peripheral vascular procedures.
• Cardiovascular and Thoracic Surgery (CCVTC™): This certification demonstrates that you possess knowledge of the treatment, equipment, and testing procedures associated with cardiovascular and thoracic surgery (surgeries performed on the heart, lungs, and greater vessels in the chest). You’ll need to possess both technical knowledge of Medicare billing rules and medical knowledge of the heart and circulatory system.
• Chiropractic (CCPC™): Chiropractic services involve manually adjusting a patient’s spinal system, which is considered complementary or alternative medicine. Medical billers and coders working alongside chiropractic professionals need to be able to navigate the specific ways that insurance companies reimburse these practitioners. You’ll also need to be aware of its diagnostic procedures in this field.
• Dermatology (CPCD™): Dermatologists diagnose and treat diseases related to the skin. Billers and coders working with dermatologists need to have knowledge of these skin conditions and related treatments. This means you’ll have to familiarize yourself with the anatomy of human skin and the classification of its disorders. You should also be knowledgeable of procedures such as debridement, lesion excisions, and flaps.
• Emergency Department (CEDC™): Billers and coders who have this specialized certification have obtained proof of their expertise in accident and trauma codes, as well as some knowledge of pain management and sedative treatments. Because this dynamic subfield requires you to work quickly on your feet, you’ll need to be very familiar with associated codes.
• Evaluation and Management (CEMC™): The healthcare industry relies upon a system of classifying codes not only to bill insurance companies, but also to track health information for planning purposes. Coding professionals in this specialization work to manage the costs incurred by medical offices and hospitals and help ensure quality treatment. As you’ll be tested on both billing regulations and your coding proficiency, you’ll do best after earning broad professional experience in the field.
• Family Practice (CFPC™): There’s a variety of health information that billers and coders must manage in family practice settings. You’ll need to understand general insurance reimbursement regulations and know how to accurately sequence codes when several procedures are performed together (as in an annual checkup.) You should also have general knowledge of pediatric medicine.
• Gastroenterology (CGIC™): Gastroenterology is the field that treats gastric disorders. You’ll need to be knowledgeable about each abdominal organ in order to code very specific conditions and procedures. You can expect to learn codes used for procedures such as ERCPs, colonoscopies, and esophageal dilations.
• General Surgery (CGSC™): This certification demonstrates your expertise in the field of billing and coding surgical procedures. With a variety of surgeries performed each day, you’ll be tasked with quickly and accurately transcribing operating room notes into codes. You’ll need to also understand the set of rules regarding private and public insurance reimbursement. The AAPC recommends that you complete this certification after having plenty of work experience as this exam is based on simulated coding scenarios.
• Hematology and Oncology (CHONC™): This certification signifies that you have an expertise in coding issues related to the treatment of cancers and blood disorders. These can include bone marrow treatments, chemotherapy and hydration, and blood tests. These procedures are particularly complex, requiring that billers sequence on-going care that requires a number of treatments. Insurance providers also have stipulations about compensation for surgeries and drug-based forms of disease treatment and management.
• Internal Medicine (CIMC™): Internal medicine is the treatment and prevention of adult diseases. You’ll have to be comfortable using codes to classify vaccinations, blood draws, and other minor procedures and surgeries. This specialty requires high attention to detail and accuracy, and your best preparation for the exam is real-world experience.
• Obstetrics Gynecology (COBGC™): This medical coding specialty requires training and experience working in women’s health. To manage the health records and information in an OB/GYN office, you’ll need to be familiar with the procedures used in prepartum, postpartum, and childbirth care. You’ll have to stay up-to-date on gynecological concerns and complex sets of regulations maintained by insurance providers.
• Orthopaedic Surgery (COSC™): Coding orthopaedic surgeries requires a basic familiarity of the anatomy of the human skeletal system and its functions, as well as its related surgeries. These include fracture repairs, spinal surgeries, and other types of procedures for a variety of disorders. You’ll also need to demonstrate knowledge of insurance and billing regulations, including Medicare rules regarding shared visits, teaching situations, and consultations.
• Otolaryngology (CENTC™): Billters who work in the ENT specialty (ear, nose, and throat) have to learn the diagnostic procedures and treatments used by ENT specialists, including nasopharyngoscopies, laryngoscopies, and sinus surgeries, The AAPC recommends having work experience in this field because it requires a familiarity with insurance regulations, Medicare, and billing procedures for common surgeries and procedures.
• Pediatrics (CPEDC™): Achieving this professional certification demonstrates that you have training and experience managing the health information of children. You will need to possess general knowledge of pediatric medicine, as well as common procedures (like immunizations.) Pediatric care also requires knowledge of a wide range of treatments, many including multiple procedures or visits. The examination for this certification is based on sample doctor’s notes, so it’s a great advantage to have professional experience.
• Plastics and Reconstructive Surgery (CPRC™): Coding procedures for this field of medicine can be complex because of the highly specific kinds of procedures and surgeries performed. Because this field is also the site of elective and cosmetic procedures, you’ll need to organize data accurately for patients who are undergoing restorative surgeries so their insurers can cover their expenses. Medical coders who have experience working with plastic surgeons are more likely to succeed on this certification examination.
• Rheumatology (CRHC™): Rheumatology is the study of the treatment of joint disorders, such as arthritis. Medical billers and coders who earn this certification demonstrate general knowledge of the procedures, treatments, and medical devices and equipment used in patient care. You will also need to have an understanding of Medicare and other forms of public and private insurance billing procedures. Rheumatologists work with patients over multiple visits, and treatment can be extensive, which requires rheumatology coders to keep track of repeat treatments.
• Surgical Foot and Ankle (CSFAC™): To earn this certification, you’ll have to develop knowledge of common foot and ankle problems, as well as their associated medical treatment options and equipment. You’ll have to turn doctor’s notes into codes that accurately convey the forms of treatment provided, and know the ins and outs of Medicare and insurance billing. The AAPC recommends that you have significant clinical experience as a coder in this subfield before taking the certification examination.
• Urology (CUC™): Medical coders working with urologists must develop an understanding of urinary tract issues for patients of both genders, as well as knowledge of male reproductive health issues. If you choose to specialize in this subfield of medicine, you’ll need to accurately code ancillary procedures performed in a urologists’ offices, such as injections and urinalysis. You’ll also have to be familiar with codes for procedures performed in hospitals, such as biopsies, cystoscopies, and prostatectomies.

AMBA certification

The American Medical Billing Association (AMBA) confers the title of Certified Medical Reimbursement Specialist to qualified individuals who pass its certification exam. AMBA also offers a certificate program that teaches medical terminology and ICD-9, ICD-10, CPT, and HCPCS standards for coding medical procedures. You’ll also learn about state and federal regulations, as well as insurance company policies and practices.

AMBA doesn’t recommend taking the exam unless you have on-the-job medical experience, or some other education in medical billing and coding. Continuing education and membership to the organization are also requirements of this certification.

AHIMA certification

The American Health Information Management Association (AHIMA) offers several general medical coding certifications, which demonstrate the proficiency and accuracy required to work in hospitals, clinics, nursing homes, care centers, and private coding businesses.

Certified Coding Assistant (CCA): This is the general-purpose certification for professional coders. The exam requires a high school diploma, but the association encourages medical coding experience or training. AHIMA also requires 20 continuing education units biannually, as well as a fee to remain certified.

Certified Coding Specialist (CCS): This certification is for coders who use their coding skills in a clinical environment, like large hospitals and research institutions. This designation requiresspecialized training and/or experience, and you’ll need to brush up on your accuracy and proficiency with code systems in order to pass the exam. You’ll also need 20 units of continuing education and a fee to remain certified.

Certified Coding Specialist – Physician-Based (CCS-P): This certification program emphasizes the coding used in physicians’ offices and private practice work environments. AHIMA recommends that you’ve had some combination of work experience or education in coding or managing health records and health information. Like the other AHIMA certifications, this also requires 20 continuing education units every other year (which can be earned from a variety of sources, so check the website for details.)

Pass the AAPC Certified Professional Coder Examination

The AAPC offers twenty-one specialty examinations in medical specialties, such as cardiology and pediatrics, which you can take without earning a CPC or other certification. These exams are conducted in the same way as the CPC exams, but the content can vary slightly. Take a look at the AAPC’s list of specialty credentials to see what coding and other topics you will need to study.

Planning for the Exam

As noted above, the AAPC offers three main medical coding certifications and a number of specialized additional certifications, all of which are earned by examination. All of these examinations are multiple-choice based in medical coding, with some access to a medical coding manual allowed. In addition, the CPC-P exam includes questions on health insurance reimbursement.

All of AAPC’s exams are structured in a similar way: 150 multiple-choice questions, with the exam proctored at a specific location. The subjects of those questions vary; a CPC exam covers most topics in a general sense, while the other exams get increasingly focused on specific skills. All their exams provide you with five hours and forty minutes to finish, as well as providing you with an opportunity to retake the exam once at no additional cost.

AAPC charges a set fee for each of their examinations, which includes membership in the group – $300, or $260 if you have joined AAPC as a student. There is no formal educational requirement, although AAPC recommends that you earn an associate’s degree. You will also need to have two years of experience as a medical biller and coder to be fully certified. However, if you complete the exam without this work experience, you will still receive certification as a coding apprentice (CPC-A, CPC-P-A, etc.) and will earn your full credential as long as you work in the field and complete continuing education.

When you arrive at the exam site, you will be permitted to bring coding manuals with you. Here’s what you can bring:

• A CPT book (AMA standard or professional edition); no other publisher’s work is allowed.
• An ICD-9-CM codebook of your choice.
• An HCPCS Level II codebook of your choice.
• Officially published corrections to any errors in the above books.
• For specialty exams only, relevant anatomical charts and sample worksheets for the specific field you are testing on; check the AAPC site for full details.

The questions in the exam are structured so that these books, as well as reasoning and understanding of medical terminology, anatomy and physiology, will permit you to succeed.

You will also need to continue studying in order to keep your certification, along with remaining a dues-paying member of AAPC. You will be expected to complete 36 Continuing Education Units (CEUs) every two years. This is less demanding than it may seem; you can earn a CEU each month by completing an small test in AAPC’s journal, and workshops, online webinars and conferences give you plenty of opportunities to make up the difference.

Preparing for the Exam

AAPC offers a range of exam preparation products, and there is a great deal of material on medical billing and coding available at bookstores. What’s more, you may already be studying medical billing and coding as well as related topics in formal courses at a school or other institution. Here are some tips that may help you prepare more effectively, as well as deal with other problems leading up to your certification exam.

• If you’re stressed by the prospect of an expensive exam, remember that your payment comes with one free retest. AAPC will provide you with a full report of how you performed, including exact scores and notation of areas where you need to focus your studies. It may be helpful to think of your first try as practice.
• Remember that you are permitted to bring in codebooks; you will not need to memorize the entire coding system you are being tested on, but instead you will need to know how to quickly and efficiently find out the codes you need. Focus your practice on learning to look up codes quickly and accurately, as well as on medical terminology.
• A powerful way to study uses flash cards. Write down the information you are studying on a series of them, and go through the entire stack. If you get one right, place it in the “once weekly” stack; if you get it wrong, place it in the “once daily” stack. Review the “once daily” stack daily, moving correct answers into the “once weekly” stack, and do the same for the “once weekly” stack. This combines regular review with a focus on what you truly need to cover.

Study Guides

These resources can help you prepare yourself for medical billing and coding certification. Some of these are unofficial and others are produced by the AAPC or other professional groups.

• Quizlet: Medical Billing and Coding – This resource provides you with free, student-made online “quizlets”. There is no cost for them, and you can be certain they were made to address genuine student needs.
• ICD9.chrisendres.com – A free and searchable guide to ICD-9’s code standards, which are the primary topic of your certification exams.
• Step-by-Step Medical Coding (2013 edition) – A guide to understanding medical coding by a veteran in the field. The latest update to a long series of yearly issues; earlier editions are still largely valid, although you should look up, and keep in mind, what changes have taken place in coding practice.
• Official CPC Certification Study Guide – Published by the AAPC and written by the same panel that writes the CPC exam, you can be certain this guide will tell you what you need to know. It includes sample questions of all sorts, a specially prepared study guide, and a series of practical examples.

Sample Tests

Taking practice examinations can help you find your own weak spots for further study, as well as having benefits as a learning practice in its own right. These are some sources for sample medical coding and billing tests, which will let you test your learning without pressure and at little or no cost.

• Ritecode.com: Medical Coding Consultants – These training specialists provide a wealth of resources on the AAPC certification exam and other medical coding topics. Look for the light blue entries to find the free resources.
• Career Coders: Test your Knowledge – These sample questions, provided by a medical billing and coding instructional company, let you test your knowledge in specific fields, such as ICD-9, Medicare/Medicaid, and medical terminology.
• AAPC – Online Practice Exams – AAPC offers a series of online practice exams in all of their certification, providing you with quick feedback, detailed explanations of the reasoning behind various questions’ answers, and as many retakes as you like. They are only available for a fee, although you will get a substantial discount with AAPC membership.

Medical Billing Errors

As a medical billing specialist, it’s critically important that you minimize any coding and processing errors as you file claims. Healthcare providers receive the majority of their revenue through the processing of successful claims, so any mistake you make could cost your employer. This course is designed to help you avoid the most common errors and keep denied and rejected claims at a minimum.

Understanding the Difference Between a Denied and a Rejected Claim

First, you need to know the difference between a denied claim and a rejected claim. A denied claim is one that has been determined by an insurance company to be unpayable. Typically, insurance companies explain the reasons in the Explanation of Benefits (EOBs) attached to the claim. Claims are often denied because of common billing errors or missing information, but can also be denied based on patient coverage. Denied claims can be appealed and reprocessed in some cases.

A rejected claim has been rejected because of errors. An insurance company might reject a claim because a medical billing specialist incorrectly input patient or insurance information. Once a medical billing specialist amends the errors on a rejected claim they can resubmit it for processing with an insurance company.

Common Errors Made When Filing a Claim

It is easy to overlook parts of a claim when you’re processing many in a given day. But if you can identify some of the more common mistakes medical billing specialists make, you can try to avoid them. Here are some of the most common mistakes made when filing a claim:

• Entering incorrect information for the provider (name, address, contact information, etc.)
• Entering incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)
• Entering incorrect information for the insurance provider (policy numbers, address, contact information, etc.)
• Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes
• Entering too few or too many digits for ICD-9-CM codes
• Inputting mismatched treatment and diagnostic codes
• Forgetting to input codes at all for services performed by a physician or another healthcare official

Again, every piece of information on a claim has to be accurate in order for it to be processed correctly. It is particularly important to make sure the correct codes are used. Be sure to familiarize yourself with all the relevant codes as well as patient, provider, and insurance information prior to filing a claim.

Other common billing errors include the following:

• Not having access to EOBs on denied claims: Sometimes an insurance company may forget to attach the EOB to a denied claim. In these cases, you won’t know the reason the claim was denied because the insurance company didn’t provide it at all or it was mistakenly sent to another provider. You can minimize problems with the EOB by keeping track of denied claims as soon as you receive them from insurance companies.
• Not verifying a patient’s insurance coverage: A patient’s health insurance can change at any time, sometimes without the patient knowing it. As a medical billing specialist, part of your job is to verify insurance coverage.
• Duplicate billing: Duplicate billing is an issue that occurs when you bill for the same service more than once. This might happen if more than one person at a provider’s office reports that a patient received services without checking whether or not those services had been paid for. The best way to avoid duplicate billing is for you to be extra vigilant about suspicious entries on a patient’s superbill and to communicate your concerns to a physician about them.

Some billing errors are simply beyond your control including the following:

• Upcoding: Upcoding occurs when physicians or medical coders enter codes into a patient’s superbill for services not received. Typically this is done to inflate the total amount a patient owes for receiving care at a healthcare provider. Upcoding is illegal and can lead to fines and criminal prosecution.
• Undercoding: Undercoding occurs when a physician or a medical coder leaves out codes from a patient’s superbill or codes them for less treatment than they actually received. Healthcare providers might undercode for healthcare services in an attempt to avoid audits or to minimize a patient’s cost. Undercoding is also illegal and can have legal repercussions.
• Sloppy documentation: Medical billing errors can also arise when physicians or other healthcare providers turn in sloppy documentation to medical billing specialists. A physician might have illegible handwriting, for example, making it hard to assign codes and bill for a patient’s healthcare. A physician’s documentation may also cause you to inadvertently undercode a patient’s bill.

How to Catch and Correct Errors Early

To avoid common medical billing: stay vigilant about simple mistakes on your end, be thorough when reviewing a patient’s superbill, and consult with your physician whenever you have questions about what should or shouldn’t be billed for. Most medical billing errors can be avoided well before claims are sent for processing with an insurance company, and it’s up to you to keep the claims moving through the system quickly and accurately. Here are a few tips to help you stay on track:

• Coordinate with everyone at the provider’s office: You aren’t the only person responsible for the information you in a claim. The physician who administered the actual healthcare and the personnel who collected a patient’s co-pay and insurance information also contributed to the superbill. So if you have any concerns about a claim, you can check with them to work out any issues before submitting the claim.
• Double-check patient and insurance information before filing a claim: Entering patient and insurance information incorrectly is one of the easier mistakes to avoid, but they still happen. The strategy for avoiding this mistake is simple: double-check your work.
• Study billing and coding trends: You can guard against coding mistakes by staying up to date on the latest medical billing codes. Medical billing codes change over time to accommodate modifications in healthcare regulations, newfound illnesses, and new treatments for illnesses and conditions. Be sure to study new codes and billing procedures as they become available.
• Follow up on claims: You can avoid and anticipate errors by following up on claims filed with insurance companies. A representative working on the claim for the insurance company might be able to tell you of any errors they find on their end, and thereby provide you with an opportunity to resubmit a claim before it gets denied.

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?