AR Manual - Issues and Actions PDF

**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...

**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?