Doctors Office
Billing Office
Patient Treated
Insurance Details Collected from the Insurance Card (Raw Details)
Receivables Management
Coding
Charge Entry
Client Software
Cash Posting
Providers
Some of the Possible Scenarios
Claim Not In System Claim Denied For Exceeding the Filing Limit Insurance Not Able To Identify Patient Claim In Process No Coverage For Date Of Service Claim Paid To The Patient Payment Applied To Deductible Claim Denied As A Duplicate Claim Denied As Maximum Benefits Met Claim Denied As The Diagnosis Code Being Inconsistent With
The Procedure Code Capitated Payment Claim Denied For No Referral Or Prior Authorization Claim Denied As Provider Is Non-Par Claim Denied Due To Incorrect Modifier Claim Denied For Primary Explanation Of Benefits Claim Denied For Non-covered Service
Procedure Not Payable Claim Denied As Mutually Inclusive Claim Offset Claim Denied As Pre-Existing Condition Claim Paid / Claim Paid To Wrong Address Claim Denied For Medical Records
Not Active
Active Available Not AvailableAvailable
No Yes
Not Available
Claim Not In SystemClaim Not In System
Verify Patient EligibilityVerify Effective Date of PolicyVerify Status of Coverage
Get Claim Mailing Address, Phone No., Fax No., Filing Limit (For In-Network and Out of Network provider) & Processing time
If Claim filed within the Filing Limit
If within the time frame, Mail / Fax the claim to the Insurance. If Filing Limit exceeded, appropriate action code is marked on the account for client’s action
Mail / Fax the claim with the proof (System / NEIC)
Check for other Insurance Coverage Check for other Insurance Coverage with the Representativewith the Representative
Get Insurance Name, Address, Phone No., Id No., other Insurance Information.
Verify for other Verify for other Insurance details in the Insurance details in the systemsystem
Call the available Insurance to verify eligibility
Get Claim Mailing Address, Phone No., Fax No., Filing Limit & Processing time
Bill the claim to the Insurance
Call Patient, get the required Insurance Information
Claim Denied for Exceeding the Filing Claim Denied for Exceeding the Filing LimitLimit
Within the Not Within the Timely Filing Limit Timely Filing Limit
Yes Yes No With Appeal
Get Denial Date
Verify with Insurance, when the claim was received for the first time & get the Filing Limit for submission
Update the same with the Insurance and get the claim reprocessed
Get the claim Ref. No and reprocessing time for further follow up
Mail / Fax the claim with the Proof (System / NEIC)
Get Appeal Mailing Address, Phone No., Fax NO., & Processing Time for further follow up
Appropriate action code is marked on the account for client’s action
Verify for the billed Verify for the billed status in the Billing status in the Billing system, if filed earliersystem, if filed earlier
Insurance Not Able To Identify Insurance Not Able To Identify PatientPatient
AvailableNot Available
Available
Not Available
NotAvailable
Available
Not Eligible
Eligible
Eligible
Ensure if reached the right Insurance
Request for SSN Search (If different from ID#)
Request for Name / Address / DOB Search
Check any other Insurance details available in the Billing Software
Get the correct ID No. of the patient and the eligibility details
Get the status for date of Service in question
Appropriate actions taken according to the status
Call patient and find out the required details Call Insurance to
check if patient is eligible
Get Claim Mailing Address, Phone No., Fax No. & Processing Time
Mail / Fax to the Insurance accordingly
Claim in ProcessClaim in Process
Get the date on whichInsurance received the claim for the first timeClaim was sent for processing / reprocessing
If claim is in process for a long time get the reason for the delayGet the processing time and claim Ref. No. for the claim
Follow up on the appropriate date
No Coverage for Date of No Coverage for Date of ServiceService
Get detailsClaim processed dateThe Effective date of coverageDate of termination
Verify if any Claim has been paid after the termination
Check in both Billing software and the insurance, if the patient has any other insurance coverage.
Call the other insurance and check for eligibility status
Call the Patient and get the appropriate information.
Verify the Date of service with the Insurance
Update the insurance with correct details and the claim reprocessed
Get the reprocessing time and Claim Ref. No for further follow up
Update the Insurance information and file the claim
Claim Paid To the PatientClaim Paid To the Patient
Get the date on which the Claim was processed
Get the reason why the Claim was paid to the patient
Appropriate action code is marked on the account for client’s action
Get any other Payment details available (amount paid etc)
Payment Applied To Payment Applied To DeductibleDeductible
Get the claim processed date and amount applied to deductible
Verify the details if the claim processed underIndividual ProviderGroupIn-networkOut-network
Cases IdentifiedIndividual Provider & In-networkIndividual Provider & Out-networkGroup & In-networkGroup & Out-network
Get the claim processed date and amount applied to deductible
Appropriate action code is marked on the account for client’s action
Get the denial date and status of the Original Claim
Claim Denied As Claim Denied As DuplicateDuplicate
VerifyDiagnosis Code Procedure CodeBilled AmountProvider’s NameModifier etc(if any)
Get the appeal address and the time frame within which the claim has to be appealed (with supporting medical document if required)
Appeal and Follow up on the appropriate day
Same Different Claim Claim
Possible casesSame provider rendering two different services on the same dayTwo different providers rendering different services on the same day.
Claim Denied As Maximum Benefits Claim Denied As Maximum Benefits MetMet
Match details Does not (Correct) match details
(Incorrect)
Verify detailsMaximum Benefits detailsThe total benefits amount as per the patient’s plan Date on which maximum benefit met
Get detailsIn-Network or Out of Network benefits.Benefits for the calendar year
Appropriate action code is marked on the account for client action
Update the Insurance with the appropriate details and get the claims reprocessed.
Get the reprocessing time and Claim Ref.No. for further follow up
Claim Denied As Diagnosis Code Being Claim Denied As Diagnosis Code Being Inconsistent With the Procedure Inconsistent With the Procedure CodeCode
Correct Incorrect
Verify the diagnosis with the procedure (CPT Code)
Update the Insurance with the appropriate details and get the claims reprocessed.
Get the reprocessing time and Claim Ref. No. for follow up
Get the reason for the inconsistency
Get the mailing address and the time frame by which corrected claim needs to be submitted
Get Denial Date
Capitated Capitated PaymentPayment
Under UnderIndividual GroupProvider
Physician Physician Is a PCP is a Specialist
Verify if the claim was received under individual provider / Group
Verify if rendering physician is a Primary Care Physician (PCP). Verify the same with the Billing software
Get the effective date of the capitation contract and mark on the account for client’s action
Get the effective date of the Capitation contract (If Possible)
Update the insurance with the appropriate details and get the claim processed
Get the Date on which the Claim was processed under capitation
Get the reprocessing time and Claim Ref. No. for further follow-up
Claim Denied For No Referral or Prior Claim Denied For No Referral or Prior AuthorizationAuthorization
Get Denial Date
Ref No. / Auth No. Ref No. / Auth No. Found in system not found in system
Correct Incorrect
Get if the insurance requires a prior authorization from Utilization Management Department of the Insurance or a Paper Referral from the Primary Care Physician (PCP)
Update the Insurance with the required Ref. No. / Prior Auth No. and get the claim processed
Get the reprocessing time and Claim Ref. No. for follow up
Verify InformationIf Prior Auth. No. required is
sent to providerIf paper Referral is required,
verify if the rendering provider is a specialist or a PCP
Follow up on the claim
Claim Denied As Provider Is Non-ParClaim Denied As Provider Is Non-Par
Verify for Referral or Prior Authorization No. in the Billing System
Get patients PCP’s Name and phone No. incase the rendering physicians specialist / PCP but not patients PCP.
Request (Ref / Auth) sent to the respective provider every 15 days for 3 times. When responded by the client, Claim is re-filed with Medical Records to the insurance
If the rendering Physician is patient’s PCP, Update the same with the Insurance and get the claim reprocessed
Provider Par Provider Non-Par
Yes
NO
Get Denial Date
Update the Insurance with the correct information and get the claims reprocessed.
Verify the Tax ID No. with the insurance and check if the provider is In-Network from the Billing System.
Verify if the patient has any out of Network benefits as per the policy plan
Get the reprocessing time and Claim Ref. No. for follow up
Appropriate action code is marked on the account for client action
Claim Denied Due TO Incorrect Claim Denied Due TO Incorrect ModifierModifier
Correct Incorrect ModifierModifier
If Required With Appeal
Get Denial Date
Update the Insurance with the correct information and get the claims reprocessed.
Verify the Modifier details in the Billing system and with the Insurance
Get the reason for the incorrect modifier
Get the reprocessing time and Claim Ref. No. for follow up
Mail / Fax the claim with the correct modifier
Get the appeal address and the time frame within which the Claim has to be applied
Appeal and Follow up on the appropriate day
Claim Denied For Primary Explanation of Claim Denied For Primary Explanation of BenefitsBenefits
Secondary Primary Insurance Insurance
Get Denial Date
Get the mailing address and the time frame by which corrected claim needs to be submitted.
Verify in the Billing system, if the Insurance is the secondary payor for the patient
Update the Insurance with the correct information and get the claims reprocessed.
Re-file the claim with the Primary EOB and follow up on the same
Get the reprocessing time and Claim Ref. No. for follow up
Claim Denied As Non-Covered ServiceClaim Denied As Non-Covered Service / Procedure Not Payable/ Procedure Not Payable
Paid Unpaid
Yes No
Get denial date and reason for denial
Update the Insurance with the correct information and get the claims reprocessed.
Check for the benefits under the patients plan and verify if the Insurance has paid for the same procedure code previously for any other Dates of Services
Check if the claim could be appealed
Get the reprocessing time and Claim Ref. No. for follow up
Appropriate action code is marked on the account for Clients action
Get the appeal address and the time frame within which the Claim has to be appealed
Appeal and Follow up on the appropriate day
Claim Denied As Mutually InclusiveClaim Denied As Mutually Inclusive
Paid Unpaid
Yes No
Get the denial date and the procedure to which the service is denied as Inclusive
Update the Insurance with the correct information and get the claims reprocessed.
Verify if the Insurance has paid for the same procedure code for any other dates of service
Check if the claim could be appealed
Get the reprocessing time and Claim Ref. No. for follow up
Appropriate action code is marked on the account for Clients action
Get the appeal address and the time frame within which the Claim has to be appealed
Appeal and Follow up on the appropriate day
Claim OffsetClaim Offset
Get the date on which the Claim was processed
Get the approved amount and the Offset amount
Appropriate action code is marked on the account for client’s action
Get the details about the Account for which an excess payment was madePatient Name and ID No.Date of ServiceBilled amount and excess amount
Request for an Explanation of Benefits
If the Waiting Period If the Waiting PeriodIn Effect / Insurance Not in Effect / Insurance
Paid for any other DOS Not paid for any other DOS
No Yes
Claim Denied For Pre-Existing Condition
Get Denial Date
Get the details aboutPre-existing clauseWaiting PeriodEffective Date of Coverage
VerifyIf the waiting period in effectIf insurance has paid for the same procedure code for any other dates of service.
Update the insurance with the appropriate details and get the claim reprocessed.
Check if any pre-existing questionnaire was sent to the patient or the provider.
Get the reprocessing time and Claim Ref .No. for further followup
Request for the Pre-Existing questionnaire
Get Date on which questionnaire was sent and the queries made.
Get the address / Fax No. where the filled questionnaire needs to be sent and followup on the same.
If paid to Correct If Paid to Wrong Address Address
Correct
Uncashed Cashed Incorrect
Claim Paid / Claim Paid To Wrong Address
Get the date on which the Claim was processed and paid
Get Payment DetailsAllowed amountPaid amount (if more than 1 procedure, Break-up amount required)Co-pay amountPatient responsibility (if any)Provider write-off (if any)
Get the Check DetailsCheck NumberCheck DateTotal Amount on the Check
Verify the Pay-to-Address(Payment mailing address)
Verify if the check has been cashed
Verify Tax ID No. under which the Claim was processed and the pay-to-address corresponding to the Tax ID No.
Verify if the Check has been cashed
Get the procedures for updating the correct pay-to-address and get the time frame for the same.
If more than 15 days from the encashment date, request for a copy of cancelled check and EOB
Get the encashment Date
Appropriate action code is marked on the account for client’s action.
If more than 180 days from the Check Date; Request for a check tracer / stop payment for a reissue of a new check.
Received Not Received
Claim Denied for Medical Records
Get Denial Date
Verify in the AHS system if medical records were sent earlier.
Request (Medical Records) sent to the respective provider every 15 days for 3 times. When responded by the client, Claim is re-filed with Medical Records to the Insurance.
Update the Insurance with the appropriate details and get the Claim reprocessed.
Get the reprocessing time and Claim Ref. No. for further follow up Follow up on the Claim.