Ar Scenarios V1.1 PDF

AR Scenario No Claim on File No claim on file ↓ May I have policy effective and termed date? ↓ Check D...

AR Scenario No Claim on File No claim on file ↓ May I have policy effective and termed date? ↓ Check DOS lies between effective and termed date ↙ ↘ Yes No ↓ ↓ May I have the TFL? ← ← Is there any other policy ↓ ↖ active for the patient on DOS? Check DOS lies within TFL ↙ ↘ ↙ ↘ ↖ Yes No Yes No ↓ ↓ ↓ ↓ ↖ May I have May I get May I have claim Can we fax or Policy ID, Policy call ref#? mailing address, mail the claim effective and Payer ID and Fax#? along with POTF? termed Date? ↓ ↖ ↙ ↘ May I get call ref#? ↖ ← No Yes ↓ May I have Fax# or Mailing address to send claim along with POTF? ↓ May I get call ref#? Claim paid & applied towards offset Claim paid & applied towards offset ↓ May I get processed and paid date? ↓ What are the allowed amount, paid amount and patient responsibility (Coins, Deductible or Co-payment)? ↓ May I know the reason, why is it applied towards offset? ↓ May I know to which patient is it applied towards offset? ↓ May I know the patient account#, DOS & CPT? ↓ Could you please fax the EOB? if not then mail it or provide the source to get the EOB? ↓ May I know the claim# & call ref#?  AR Scenario Claim in Process Claim in process ↓ When did you receive the claim? ↓ What is the normal processing time or TAT? ↓ Calculate TAT from received date and check if is it within the TAT? ↙ ↘ Yes No ↓ ↓ May I get Claim# May I have the & Call ref#? reason for delay? ↙ ↓ ↘ ⟶⟶ ↙ ↓ ↓ Any Information Information requested Other Reasons or documents from patient (Backlog) requested from ↓ ↓ provider Have you sent May I get ↓ letter to patient? Claim# & What documents/info ↙ ↘ Call ref#? requested? Yes No ↓ ↓ ↓ May I have the When did May I get address or Fax# to you send Claim# & send the document/info? the letter? Call ref#? ↓ ↓ May I get Claim# May I get & Call ref#? Claim# & Call ref#? Claim Paid to Patient Claim Paid to Patient ↓ What is the processed & paid date? ↓ What are the allowed amount, paid amount and patient responsibility (Coins, Deductible or Co-payment)? ↓ Verify sum of PA and Patient Responsibility(PTR) equals to AA, if not then probe the rep and get the correct information ↓ Why was the claim paid to patient? ↓ May I have the claim# & call ref#  AR Scenario Set to Pay/Approved to Pay Approved to pay ↓ What is the processed date? ↓ What are the allowed amount, paid amount and patient responsibility (Coins, Deductible, or Co-payment)? ↓ Verify sum of PA and Patient Responsibility(PTR) equals to AA, if not then probe the rep and get the correct information ↓ When can we expect the payment? ↓ May I have the claim# & Call ref# AA = PA + PR/PTR AA = Allowed Amount PR/PTR = Patient Responsibility PA = Paid Amount BA = AA + CA BA = Billed Amount CA = Contractual Adjustment Denied as patient enrolled in Hospice Claim denied as patient enrolled in Hospice ↓ May I get the denial date? ↓ May I have the start date and end date of the hospice enrollment? ↓ Check if DOS lies between hospice enrollment date ↙ ↘ No Yes ↓ ↓ Could you please send the Can I get the hospice information claim back for reprocessing since such as hospice name, NPI, mailing address patient not enrolled in hospice on dos? & policy ID? ↓ ↓ What is the TAT for May I get the Claim# reprocessing? & Call ref#? ↓ May I get the Claim# & Call ref#?  AR Scenario Claim Paid Claim Paid ↓ What is the processed & paid date? ↓ What are the allowed amount, paid amount and patient responsibility (Coins, Deductible or Co-payment)? ↓ Verify sum of PA and Patient Responsibility(PTR) equals to AA, if not then probe the rep and get the correct information ↓ Was payment done through Check or EFT/Credit Card? ↙ ↘ Check EFT/Credit Card ↓ ↓ What is the check#? What is the Transaction ID? ↓ ↓ Was it Single check or Bulk check#? Was it single payment or Bulk payment? ↙ ↘ ↙ ↘ Single check Bulk Check Single payment Bulk payment ↘ ↓ ↘ ↓ ↘ What is the Bulk Amount? ↘ What is the Bulk Payment Amount? ↘ ↙ ↘ ↙ May I have the check mailing address? Is payment cleared? ↓ ↙ ↓ ↘ Validate address provided by rep with Yes Not Provided No the address available in box# 01 and 02 ↓ ↓ ↓ ↙ ↘ ↓ ↓ ↓ Correct Incorrect ↓ ↓ ↓ ↓ ↘ May I have the ↓ EFT/Credit card Is the check cashed? ↘ encashment date ↓ payment takes 2-3 ↙ ↘ ↘ → → ↘ ↓ ↙ days for clearance Yes No ↘ Provide correct Could you please but not more than ↓ ↓ Rep does not check mailing fax the EOB? If 7 days. So, if the paid May I have the ↓ have encashment address to rep & not then mail it or date has crossed 7 days encashment ↓ date information? ask to reissue new provide the source then it means payment date? ↓ ↓ check to get the EOB might get canceled. So, ↓ ↓ Could you please ↓ ↘ verify same with rep & Could you please Is paid date fax the EOB? If rep agrees? May I have ask rep to reissue new fax the EOB? If crossed 45 days? not then mail it ↙ ↘ the Claim# & payment Not then mail it ↙↘ or provide the source Yes No Call ref ↓ or provide the ↙ ↘ to get the EOB ↓ ↘ rep agrees? source to get the ↙ ↘ ↘ What is the TAT? What is the ↙ ↘ EOB Yes No ↘ ↓ reason? Yes No ↓ ↓ ↘ → May I have ↓ ↓ ↓ May I have the Could you please How many days the claim# & Can I get the fax# What is What is the claim# & Call run check tracker will it take to Call ref#? or mailing address TAT? reason? ref#? to get the current clear the check? to send W9 form ↓ ↓ status of the check? ↓ to update the correct ↓ Could you ↓ Could you please address? May I have please fax the Rep agrees fax the EOB? If ↓ the Claim# & the EOB? If ↙ ↘ not then mail it May I have the Call ref#? not then mail Yes No or provide the source Claim# & Call ref#? it or provide ↓ ↓ to get the EOB the source to What is the TAT? ↓ the EOB ↓ ↓ May I have the ↓ Could you please fax the EOB? Claim# & Call ref#? May I have If not then mail it or provide the the claim# & source to get the EOB call ref#? ↓ May I have the Claim# & Call ref#?  AR Scenario Deductible Claim applied toward Deductible ↓ May I have the processed date? ↓ What is the Allowed Amount(AA)? ↓ How much is the total deductible limit on the policy? ↓ How much has patient met including this claim? ↙ ↘ If patient has met the deductible including this claim/ If patient has already met the Patient has not met the deductible including this claim deductible excluding this claim ↓ ↓ Could you please fax the EOB? If not then mail it Could you please send the claim or provide the source to get the EOB? back for reprocessing since ↓ patient has already met his May I have the claim# & call ref#? deductible excluding this claim? ↓ What is the Turn around time(TAT) for reprocessing? ↓ May I have the claim# & call ref#? Claim denied as Policy Termed Claim denied as member coverage terminated or Policy termed ↓ May I get the denial date? ↓ May I have the policy effective and termed date? ↓ Check if DOS lies between effective and termed date ↙ ↘ Yes No ↓ ↓ Could you please send the Is there any other policy claim back for reprocessing active for patient on DOS? since policy active on DOS? ↙ ↘ ↓ Yes No What is the TAT for ↓ ↓ reprocessing? May I have policy ID, May I have the ↓ Policy effective and claim# & call ref#? May I get the Claim# termed date? & Call ref#? ↓ May I have the claim# & call ref#?  AR Scenario Patient Cannot be Identified Patient cannot be identified ↓ Could you please search the patient with Name, DOB or Social Security#? ↙ ↘ If rep finds the patient If rep unable to find patient ↓ ↓ May I have the correct policy ID? May I get call ref#? ↓ Could you please check if claim is available for the DOS with correct member ID? ↙ ↘ Yes No ↓ ↘ Follow AR Scenario May I have the effective and Tool as per the claim status termed date of the policy? ↓ Check if DOS lies between effective and termed date ↙ ↘ No Yes ↓ ↓ May I get call ref#? May I have the Timely filing limit(TFL)? ↓ Check DOS lies within TFL ↙ ↘ Yes No ↙ ↓ May I have claim Can we fax or mail the mailing address, ← claim along with POTF? Payer ID and Fax#? ↖ ↙ ↘ ↓ ← No Yes May I get call ref#? ↓ May I have Fax# or Mailing address to send claim along with POTF? ↓ May I get call ref#?  AR Scenario Timely Filing Claim denied as Past timely filing or TFL expired ↓ May I get the denial date? ↓ When did you receive the claim? ↓ How much is the Timely filing limit? ↓ Check if the claim was received within TFL ↙ ↘ Yes No ↓ ↓ Could you please send the Check if POTF available claim back for reprocessing ↙ ↘ since the claim was received Yes No within TFL? ↓ ↓ ↓ Can we appeal with POTF? May I have What is the TAT for reprocessing? ↓ the claim# & ↓ What is the fax# or Mailing call ref#? May I have the claim# & address to send an appeal? & call ref#? What is the appeal limit? ↓ May I have the claim# & call ref#? Denied as medically not necessity Claim denied as medically not necessity ↓ May I get the denial date? ↓ What is the reason for medically not necessity? ↓ Check patient payment history if the same DX code paid with same CPT ↙ ↘ Yes No ↓ ↓ Can you please reprocess the claim as What is the time limit to payment received for same CPT & DX? send corrected claim? ↓ ↓ What is the TAT for reprocessing? What is the Fax# or Mailing ↓ address to send an appeal? May I have the claim# & call ref#? ↓ How much is the time limit to send an appeal? ↓ May I have the claim# & call ref#?  AR Scenario Authorization - Claim denied as Authorization Absent or Missing ↓ May I get the denial date? ↓ Check in system if Auth# is Available ↙ ↘ Yes No ↓ ↓ I have the Auth#, Can you please Do you have Auth# on file? reprocess the claim using this Auth#? ↗ ↙ ↘ ↓ ↗ ↙ ↘ Rep Agrees? ↗ Yes No ↙ ↓ ↗ ↓ ↓ Yes No ↗ ↓ Is it possible to ↙ ↙ ↘ ↗ Could you please obtain Retro What is turn Need to Auth# is use that Auth# and Authorization#? around time send an invalid send claim back for ↙ ↘ for processing? corrected reprocessing? Yes No ↓ claim ↙ ↓ ↓ May I have the ↓ What is the TAT What is the What is the claim# & call ref#? ↓ for reprocessing? procedure to address What is the time ↓ Obtain retro Auth? to send an limit to send May I have the ↓ appeal? a corrected claim# & call ref#? May I have the ↓ claim? claim# & call ref#? What is the ↓ Timely filing May I have the to submit Appeal? claim# & call ref#? ↓ May I have the claim# & call ref#? Claim denied as additional information requested from provider Claim denied as additional information requested from provider ↓ May I get the denial date? ↓ What kind of documents have you requested from provider? ↓ What is the Fax# or Mailing address to send the document? ↓ How much is the time limit to send the document? ↓ May I have the claim# & call ref#?  AR Scenario Maximum Benefits Claim denied as patient has reached the maximum benefit allowed ↓ May I get the denial date? ↓ May I know maximum benefit reached in terms of dollar or visit? ↙ ↘ In terms of Dollar In terms of Visit ↓ ↓ How much Dollar amount How many Visit is is allowed? allowed? ↓ ↓ How much dollar amount has How much visit has patient patient met excluding this claim? met excluding this claim? ↓ ↓ Has patient met the allowed dollar Has patient met the allowed visit amount excluding this claim? excluding this claim? ↙ ↘ ↙ ↘ Yes No Yes No ↓ ↓ ↓ ↓ May I have the Could you please May I have the Could you please claim# & call ref#? send the claim back claim# & call ref#? send the claim back for reprocessing since for reprocessing since patient has not met the patient has not met the the allowed dollar allowed visits amount excluding this amount excluding this claim? claim? ↓ ↓ What is the TAT What is the TAT for reprocessing? for reprocessing? ↓ ↓ May I have the May I have the claim# & call ref#? claim# & call ref#?  If a patient policy is active for secondary or consecutive payers on DOS then bill the claim.  If no other payer is active or available on DOS then release the claim to the patient.  AR Scenario Non-Covered Charges Claim denied as Non Covered Charges ↓ May I get the denial date? ↓ Is it non covered as per patient plan or provider contract ? ↙ ↘ Non covered as per patient plan Non covered as per provider contract ↓ ↓ What is the reason for non covered? What is the reason for non covered? ↙ ↓ ↘ ↙ ↘ Provide is DX or ICD-10 other CPT non covered under Other reasons out of network non covered reasons provider contract ↓ ↓ ↓ ↓ ↓ Follow as per Follow as What is the May I Check payment history AR Scenario as Per time frame to have the if payment received for same AR Scenario submit the claim# & CPT with same provider from corrected claim? call ref#? same insurance ↓ ↙ ↘ May I have the Yes No Claim# & Call ↓ ↓ ref#? Could you please send claim What is fax# or Appeal back for reprocessing since address to send the appeal? we have received payment for ↓ same procedure? How much is the appeal timely limit? ↓ ↓ Rep Agrees? May I have the ↙ ↘ claim# & call ref#? Yes No ↙ ↘ What is the TAT What is fax# or Appeal for reprocessing? address to send the appeal? ↓ ↓ May I have the How much is the appeal timely limit? claim# & call ref#? ↓ May I have the claim# & call ref#?  AR Scenario Denied as additional information requested from patient Claim denied/pending as additional information requested from patient ↓ When did you receive this claim? ↓ May I get the denial date? (If claim is denied) ↓ What information have you requested from patient? ↙ ↘ Patient needs to update COB information Other Reasons ↓ ↓ Have you sent letter to patient? Have you sent letter to patient? ↙ ↘ ↙ ↘ Yes No Yes No ↓ ↓ ↓ ↓ When did you When did patient last When did you May I get the sent the letter? update the COB sent the letter? claim# and Call ref#? ↓ information? ↓ Have you received ↓ Have you received any response from May I get the any response from patient? claim# and Call ref#? patient? ↙ ↘ ↙ ↘ Yes No Yes No ↓ ↘ ↓ ↘ Could you When did patient Could you May I get the please reprocess last update the please reprocess claim# and Call ref#? the claim? COB information? the claim? ↓ ↓ ↓ May I get the May I get the May I get the claim# and Call claim# and Call ref#? claim# and Call ref#? ref#? Medical Records Claim denied as Medical Records Requested ↓ May I get the denial date? ↓ What is the Fax# or Mailing address to send the MR? ↓ How much is the time limit to send the records? ↓ May I have the claim# & call ref#?  AR Scenario Denied for primary EOB Claim denied for primary EOB ↓ May I get the denial date? ↓ Check your system, the insurance on which you have made the call is listed as primary or secondary insurance ↙ ↘ Primary Insurance Secondary Insurance ↓ ↓ Could you please tell me which Check if payment from primary insurance is the primary insurance? insurance is received/processed ↓ by primary that can be billed to secondary Rep provided? ↙ ↘ ↙ ↘ Yes No Yes No ↙ ↘ ↓ ↓ Check box# 54 in UB04 Follow up with primary What is the policy May I have the form if paid amount of insurance & work claim id, payer id & claim# & call ref#? primary insurance is available, as per primary mailing address for if yes then it means that insurance status primary insurance? primary paid details already ↓ sent to insurance May I have the ↙ ↘ claim# & call ref#? Yes No ↙ ↘ Could you please reprocess the claim What is the Fax# or mailing as primary payment details are already address & time limit to sent on claim form in box# 54? send the EOB? ↙ ↘ ↓ If rep says it still Rep sent claim back May I have the not received for reprocessing claim# & call ref#? ↓ ↓ What is the Fax# or What is the TAT mailing address & time for reprocessing? limit to send the EOB? ↓ ↓ May I have the May I have the claim# & call ref#? claim# & call ref#?  AR Scenario Denied as other payer is primary Claim denied as other payer is primary ↓ May I get the denial date? ↓ Could you please tell me which insurance is the primary insurance? ↓ Does rep have the details? ↙ ↘ Yes No ↙ ↘ What is the effective & May I have the claim# termed date of the policy? & call ref#? ↙ ↘ Rep have the details Rep does not have details ↓ ↘ Was policy active on DOS? What is the policy id, payer id ↙ ↘ & mailing address of primary Yes No insurance? ↓ ↓ ↓ What is the Could you please May I have the policy id, payer id reprocess the claim claim# & call ref#? & mailing address since there is no active of primary primary insurance? insurance? ↓ ↓ What is the TAT? May I have the ↓ claim# & call ref#? May I have the claim# & call ref#? Denied as primary paid more than secondary allowed amount Claim denied as primary paid more than secondary allowed amount ↓ May I get the denial date? ↓ What is the allowed amount? ↓ Check in system, how much amount is paid by primary insurance? ↓ Is primary paid amount greater than or equals to secondary allowed amount? ↙ ↘ Yes No ↓ ↓ May I have the Could you please reprocess the claim claim# and Call ref#? as primary PA is less than secondary AA? ↓ What is the TAT for reprocessing? ↓ May I have the claim# and Call ref#? AR Scenario