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.