AR Analysis

Revenue Cycle Management [RCM]

Roles of various professionals involved in RCM
Roles of various professionals involved in RCM – contd…
 What is AR?
 AR is a process of reviewing the claims submitted to insurance and understand why the
payment has not been made, take necessary steps to resolve the claim and fasten the
payment.
 Account receivable management is the most important service provided by medical billing
companies. The effectiveness of this account receivable team will determine the financial
health of medical billing companies, physicians, nursing homes and hospitals.
 Analysis is the most important part of billing. An AR Analyst is a person, who monitors the
receivables to ensure that it is well within control. He should also keep in mind that the main
objective of a billing company is to maximize collections
 The other basic duties of an Analyst are as follows:
1) Constantly keep track of both electronic and paper claims.
2) Always be watchful for any major rejections or denials –clearing house/carrier.
3) Constantly watch-out for payments and EOBs from major carriers, Pay-to address,
provider numbers etc.
4) Ensure the AR days meet industry standards.
5) Co-ordinate with the Call Center crew, Client co-ordination and solve problems.
6) Ensuring the compliance with all the insurance carriers in claims submission and other
areas.
Why AR?

Balance outstanding with insurance

The payment is not received within 45 days

Claim not submitted

Correspondence received

Claim stuck in clearing house

Partial payment received from insurance

Payment received and not posted

Account resolution can be done in various ways –
Calls are only one way of resolution.
Online tools and
resources As per provider /
(Insurance website client instructions.
or Clearing house).

As per Insurance
Follow up notes.
specifications.

Verifying software,
if EOB/ ERA / ERA / Calling insurance
Correspondence via IVR
posted.

Verifying other (or)

Resolving
previous patient
visits/accounts
an account Reaching a
Representative
which was paid by
insurance.
for (Final option)

payment
How is AR created?
Incorrect /
Invalid Patient
Information

Incorrect /
Payment Invalid
Complications Provider
Information

7
Categories
Service Incorrect /
Related Invalid Claim
Complications Information

Patient
Insurance
Human Errors
Policy
Directives
How to Identify an outstanding claim?
 Overall claim Balance in greater than 0 or line level balance is greater than 0
 If the line level balance is less than the threshold provided by client – Adjust the balance
 Balance is insurance responsibility
 Claim is submitted to insurance
 45 days outstanding in terms of commercials & 30 days for federal insurance from date of submission
 EOB/ ERA is available for payment and not posted
How to identify if this is a fresh claim or an pre-
worked claim
 Fresh claim
 No previous notes – Comments screen
 No resubmissions - Transaction / Claim history
 No partial payments from insurance – Transaction screen
 No Denial posted – Transaction screen
 No Correspondence – Image attachments (IN some cases refer the image the repository)
 It is not a corrected charge – Other voided charges
 No Appeals done – Previous notes / Claim history
• If any one of the above is evident, it is a pre-worked claim

 In case of a fresh claim and there is a website, review the website to retrieve complete information about the claim in
question. If information is incomplete, place a call to insurance to get the information that is not available in the
website.
 In case of a fresh claim and there no websites available, place a call to the insurance to retrieve the status of the
claim for further action.
Work Flow of an AR

Pre-call Calling
Analysis

Role of an AR

Post call - Documentation

Additional
tasks

CONFIDENTIAL
Pre-Call Analysis
1. Check account balance

2. Check the age of the account

3. Check for insurance details (name, telephone#, address

etc.,)

4. Review notes from the time the claim was billed.

5. Check the ‘Type of bill’ (in case of UB04)

6. Check for alternate ways to resolve claim apart from

calling – Website, EOB, Contracts etc.,

7. Determine the objective of the call.

Documentation
8. Review of other accounts / patient’s history (if
necessary)

CONFIDENTIAL
Pre-requisites/ Check list for call
 Doctor / Provider information – Name, Tax id, Physical
address, Lock box address, PIN, NPI, specialty.

 Name of the patient

 DOB of the patient

 Insurance policy id / SSN

 Date of service & billed amount

 Diagnosis and Procedures billed

Documentation
 Insurance status – primary, secondary, etc.,

 Insurance telephone #

 Call back #
CONFIDENTIAL
 Denial Management
 Denials are where an insurance company does not pay a claim due to various reasons.

 Claims with multiple procedures can have payment on one and a denial on the other
(multiple status on a single account).

 If an insurance company denies a claim, it does not necessarily mean that the claim will
never get paid.

 There are many reasons a claim may be denied, and most of these claims can lead to
payment with an efficient and prompt AR Team.

Denials may lead to one / more of the following actions

 Reprocess

 Contact / bill patient

 Rebill claim / Appeal

 Review & write off

 Follow-up with same / another payor CONFIDENTIAL

Things to be considered as a ‘Last Resort’
The following should made as a last resort when all the other means have been exhausted.

 Calling the insurance – needed only when we are unable to get information through the other sources like EOB,
Insurance website, Previous notes, Previous visits and Recently paid claims
Nearly 70% of the outstanding claims can be resolved without calling using
proper analysis.
DO NOT PICK THE PHONE TO CALL UNLESS THERE IS REALLY A NEED

 Billing the patient – when all the other measures have been exhausted and the patient is responsible for making the
payment or providing the necessary information.
When a bill is sent to the patient, it usually takes a longer time to get the money.
We should always try to have the insurance pay, as far as possible, as it takes a lesser time.

 Write off – when we have exhausted all other means have the claim paid, but still the
provider cannot be paid with the best efforts.
The provider has appointed our client to get paid and not to write-off.

CONFIDENTIAL
Generic representation of an AR scenario

Date of Denial

Reason for the Denial

Check if the Denial is genuine

No
Yes / Not Sure
Reprocess
Collect all the relevant details
to resolve the issue

Recommend for any of the

post call actions -
Bill patient / Rebill / Appeal /
Write-off / Follow-up
CONFIDENTIAL
CMS / HCFA 1500 claim form – Patient Information
* Missing information / Incorrect information in any of these fields can lead to 23 scenarios
CMS 1500 claim form – Service Charges Information
Claim Status

Claim Status

Claim received at Claim denied Claim Paid Claim pended No response

insurance & is in process

To Patient To Provider Claim not on file Claim rejected

Claim not on file
Meaning: The claim has not been received at the insurance due to various reasons

Reasons:
1. The claims mailing address / electronic payor id was updated incorrectly in the billing software. The Claim was
filed to that incorrect address / payor id.
2. The claim has been rejected by the clearing house due to format errors
3. The claim has been filed to the insurance recently
4. The claim status has been checked with the incorrect insurance
5. The claim was never filed

Steps to resolve :
1. Check the claims filing history to check whether the claim was filed from our end
2. Get the correct claims mailing address/ electronic payor id from the previous notes or previous paid claims or
from insurance rep and file the claim to the updated claims mailing address/ electronic payor id.
3. Look for errors in the submitted claim. Correct them and refile to the insurance.
4. If the claim has been filed recently, allow some more time. Set a follow-up date based on the time it usually takes
for a claim to reach the insurance.
5. Verify the insurance name, contact details before checking for claim status.
1 of 2
Claim not on file – contd…

Other information to check to avoid possible denials after filing:

1. The eligibility of the patient on the Date of Service [DOS]
2. If not eligible on DOS, the availability of alternative coverages
3. Was the claim filed within the Timely Filing Limit [TFL]?
4. If the claim was filed out of TFL, what are the acceptable Proof of Timely Filing [POTF]?

Note: This scenario can be worked upon without calling.

We need to call the insurance only when we do not find claims mailing address/ electronic payor ID / Timely Filing
Limit / Eligibility details / POTF details, through any other means.

2 of 2
Claim Not on File – Call Flow
EOB - 1
Claim in process
Meaning: The claim has been received at the insurance and is in process

Claim Adjustment and Remark Codes:

OA133 The disposition of the claim/service is pending further review.

Steps to resolve :

1) Check previous notes for the earlier follow-ups

2) Get the claim received date
3) Get the normal processing time
4) If there is a delay, get the reason for the delay

Other information to check to avoid possible denials after filing:

1) Get whether any additional information is needed for processing the claim?

Note:
This scenario can be worked upon without calling.
We need to call the insurance only when we do not find claim received date/ normal processing time, through any other
means and if there is a delay in processing.
Claim in process
Get the claim received date

Get the normal processing time

Yes Processing No
Delay?

Get the reason for the delay Is any additional info needed?

Is any additional info needed? Get the possible follow-up date

Get the possible follow-up date

Get the claim#,

call ref#
EOB - 2
Patient cannot be identified
Meaning: The insurance is not able to identify the patient as their insured (or) a dependant of their insured, due to various
reasons

Claim Adjustment and Remark Codes:

PR31 Patient cannot be identified as our insured.

Reasons:
1) The patient details have been updated incorrectly
2) The incorrect insurance has been contacted

Steps to resolve :
1) Check the insurance card copy whether all the information mentioned in billing software is correct or not
2) If any information is incorrect, correct it and refile the claim
3) If all information are correct and still if the patient cannot be identified, need to check for any previous notes or previous
paid claims
4) If any previous notes or previous paid claim is available, the patient details available there can be used.
5) Update the correct information obtained either from previous notes or previous paid claims.
6) If there are no previous notes or previous paid claims, the patient has to be billed for the relevant information.

Note: This scenario can be worked upon without calling.

Patient Cannot Be Identified
EOB - 3
Claim denied as untimely filing/past timely filing
Meaning: The claim has been received at the insurance after the filing limit.

Claim Adjustment and Remark Codes:

CO29 The time limit for filing has expired.

Reasons:
1. The claim has been submitted originally after the filing limit
2. The claim has been submitted originally within the filing limit, but was received by the insurance after the filing limit.

Steps to resolve :
1. Check whether the claim received date was within the filing limit
2. If it was within the filing limit , need to call the insurance and ask to reprocess the claim
3. If it was received out of the filing limit, need to check the original submission date.
4. If the claim was submitted within the filing limit, need to call the insurance and ask for the documents accepted as Proof of
Timely Filing [POTF]
5. If the claim was submitted after the filing limit , need to raise a client review.

Note: This scenario can be worked upon without calling.

We need to call the insurance only when we want to reprocess the claim or to get the list of documents accepted as ‘Proof of
Timely Filing’
Claim Denied For Untimely Filing

APPEAL
EOB - 4
EOB - 5
Claim denied as referral missing/invalid/
Claim denied No Auth/Permission from PCP/Gatekeeper

Meaning: The insurance does not find a referral (referral auth) from the Primary Care Physician [PCP] for the
treatment .

Claim Adjustment and Remark Codes:

PR 287 Referral invalid or exceeded.

PR 288 Referral Missing

Reasons:

1) The patient has met the specialist without the permission of the PCP
2) The PCP has treated the patient
3) The plan does not need a PCP and a referral
4) The service is an Emergency service
5) The referral number mentioned billing sofware is not updated in the claim form

1 of 2
Claim denied as referral missing – contd…
Steps to resolve :

1. Check whether the PCP has given the treatment as a rendering physician. If yes, need to call insurance and request
for reprocessing.
2. Check whether the service is an emergency service [POS Code = 23]. If yes, need to call insurance and request for
reprocessing.
3. Check whether the plan is a HMO or POS [In-network provider]. If Not (PPO or POS (Out of Network Provider),
need to call insurance and request for reprocessing.
4. Check whether the referral number has been updated in the billing software. If Yes, need to call insurance and
request for reprocessing.
5. Check whether the referral number is available in any of the documents, previous notes. If Yes, need to update the
same in the billing software and send in a corrected claim/appeal
6. If still there is no referral number, need to call the insurance and enquire whether they accept a back-dated
referral. If Yes, need to get the PCP name, PCP telephone number & Appeal details.
7. If a back-dated referral is not accepted, suggest to bill patient.

Note: This scenario can be worked upon without calling. We need to call the insurance only when we want to
reprocess the claim (or) to check whether a ‘back-dated referral’ is accepted.

2 of 2
Claim Denied For No Referral
EOB - 6
Claim denied for No/Invalid Prior authorization
Meaning: The insurance does not find an authorization for the treatment denied.

Claim Adjustment and Remark Codes:

CO197 Precertification/authorization/notification absent.
CO198 Precertification/authorization exceeded.

Reasons:

1) The provider has given the treatment without obtaining the authorization from the insurance
2) The treatment is an emergency treatment (Reprocess Claim)
3) The hospital has already obtained an authorization for the same treatment (Pre-cert) – Reprocess claim

1 of 2
Claim denied for Prior authorization – contd…
Steps to resolve :

Check if Valid Auth# is available on CMS 1500 (Block # 23). If yes, give it to rep and reprocess claim

1. Check whether the POS code is ‘23’. If yes, need to call the insurance and request the claim to be reprocessed.
2. Check whether the POS code is ’21’. If yes, need to call the insurance and verify whether the hospital claim has a
pre-certification number.
3. Need to check whether the billing software has a prior authorization number updated. If yes, need to call
insurance and validate the prior authorization number.
4. If the prior authorization number is not valid or it is not updated in the billing software, need to enquire the
insurance if they can accept a retro-authorization. If so, get Utilization Management Review (UMR) department
details (Phone#/Fax#)
5. If there is no prior authorization number and a retro authorization is not accepted, need to check with client for
further action (Possibly a Write-Off)

Note:
This scenario would need calling.

2 of 2
Claim Denied For No/Invalid Prior Authorization
Call Insurance

Request rep to
Yes Is
reprocess
POS code = 23 ?
claim
No
Yes Valid Auth#
found on s/w?
No

POS code = 21 POS code is other

than 21 or 23
Is a Call Utilization
Pre-certification# No Retro Yes Management Review
available on hospital Auth accepted? [UMR] department of ins
claim? to get a Retro Auth#
Yes No
Request rep to process claim with the pre-cert#
Get clm#, Call ref#
on the hospital claim, Get f/up date.
[Post Call: Keep claim for client review]
EOB - 7
Claim paid to patient
Meaning: The insurance has sent the payment of the claim to the patient instead of the provider.

Claim Adjustment and Remark Codes:

PR100 Payment made to patient/insured/responsible party/employer.

Reasons:
1) The policy holder has not signed on the AOB form
2) The provider does not accept assignment
3) The provider is a non-participating provider

Steps to resolve :
1. Check whether the Accept assignment has been updated as ‘Yes’ (Block # 27)
2. Check whether There is Assignment of Benefits (Signature on File – Block # 13)
3. Check whether the provider PIN is updated in the billing software. If so, need to call the insurance and validate the
PIN.
4. If the PIN is valid (contracted provider) and the AOB/Accept assignment information is available, need to request the
insurance to reprocess the claim.
5. If either AOB/Accept Assignment information is not available’ or the provider PIN is invalid (non-contracted provider),
suggest to bill patient.
Note:
This scenario can be worked upon without calling. We need to call the insurance only when we want to reprocess the
claim (or) to validate the PIN.
Claim Processed & Paid To Patient
Get the processed date

Get the Allowed amount, Patient Responsibilities, Paid amount,

Check# and Check date

Verify the reason for the claim being paid to the patient

Provider is Non-par Provider did not accept AOB

Is Request rep to Is
provider non-par per No Yes block 27 in claim
reprocess claim. Get
TIN / PIN ? follow-up date. ticked?
Yes No
Claim #, Call ref#

[Post Call: Suggest provider to bill patient]

EOB - 8
Claim processed/applied to deductible
Meaning: The allowed amount on the claim has been applied to the patient’s deductible.

Claim Adjustment and Remark Codes:

PR1 Deductible Amount.

Reason: The patient has not met the annual deductible.

Steps to resolve :
1. Get the allowed amount, amount applied to patient’s deductible,
Any other pt resp, Ins Paid amt (if any)
2. Check whether the allowed amount = deductible applied.
1. If there is a balance in the allowed amount after applying the deductible, get the break-up of the balance.
2. Need to get the details about the deductible like,
a. If it is applied In-network or Out-of-network
b. Whether it is an individual deductible or a family deductible
c. The periodicity of applying the deductible – Annual or Lifetime
d. What is the Deductible Amount. How much has the patient met on the deductible amount?
e. If the deductible amount has been met, when did the patient meet the deductible amount?

Note:
This scenario does not need calling if all the required information are available from the EOB or
website or a combination of both
Claim Processed and Applied to Deductible
EOB - 9
Claim processed towards offset
Meaning: The allowed amount on the claim has been applied to compensate an overpayment on a previous claim

Claim Adjustment and Remark Codes:

OA88 Adjustment amount represents collection against receivable created in prior overpayment

Reason: The insurance has made an over-payment on a previous claim and this has to be corrected.

Steps to resolve :
1. Get the allowed amount, patient responsibilities, paid amount
2. Get the amount applied to offset
3. Check whether the allowed amount = offset.
4. If there is a balance in the allowed amount after applying to offset, get the break-up of the balance.
5. Need to get the over-paid claim details like,
a. Claim#
b. Patient name
c. Allowed amount
d. Patient responsibility
e. Paid amount
f. Check#/ EFT ref#, Check/EFT amount

Note: This scenario does not need calling if all the required information are available from the EOB or website or a
combination of both
Claim Processed & Applied Towards OFFSET
EOB - 10
Additional information required
Meaning: The insurance has pended/denied the claim for some more information which is important to process it.

Claim Adjustment and Remark Codes:

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
CO16
(Additional Information is needed from provider)
Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
PR16 (Additional Information is needed from patient)

Reasons:
The insurance needs more information on the claim to process it. This may be from the provider or from the patient.

Steps to resolve :
1. Get the information on who needs to provide the additional information – whether the patient or the provider
2. Get the additional information that is needed . For example,
 From Patient – Coordination of Benefits (COB), Student details, Accident details
 From Provider – Medical Records (Specific M/R), Documents for Credentialing (W9 Form), Primary EOB
3. Get the, appeal address, appeal limit, appeal fax, attention to send appeal (In case of Info required from Provider)

Note: This scenario does not need calling if all the required information are available from the EOB or website or a
combination of both
Claim pending /denied for additional Information
EOB-11
Claim is Capitated/ Processed towards Capitation
Meaning: The rendering provider has executed a capitation agreement with the insurance. The insurance is providing
monthly prepaid payments to the provider (PMPM). Hence no separate payments would be made for this claim.
Claim Adjustment and Remark Codes:

CO24 Charges are covered under a capitation agreement/managed care plan.

Reason:
The treatment rendered is covered under the capitation contract executed by the provider with the insurance.

Steps to resolve :
Check whether the provider is a contracted provider. If no, call insurance and request the rep to reprocess the claim.
1. If yes, Check whether the procedure code is covered under the capitation contract.
2. If No, request the rep to reprocess the claim.
a) If Yes, check whether the DOS falls within the contract period.
b) If No, check whether there are any claims paid recently for the provider for the same procedure within the
contract period.
i. If Yes, request the rep to reprocess the claim.
ii. If No, suggest provider to write-off balance.

Note: This scenario needs calling.

Claim Capitated/Processed towards Capitation
EOB-12
Claim denied as provider Non – Par/Non Contracted/OON Pt Has no OON
Benefits
Meaning: The patient has taken treatment from a rendering provider who is not contracted with the insurance. The
insurance will not cover such services.

Claim Adjustment and Remark Codes:

PR147 Provider contracted/negotiated rate expired or not on file.

Reasons:
1) The patient has chosen a HMO plan and has taken a non-emergency service from a non-contracted provider.
2) Provider never had a contract with the insurance.
3) The provider’s contract was not in effect on the DOS.
4) The provider has renewed or revived the contract. But the details have not been updated at the time of
adjudication (Insurance Mistake)
5) The patient has a managed care plan (PPO/POS) that pays for a non-contracted provider’s services. But the
insurance has applied the processing rules for a HMO plan (Insurance mistake)

1 of 2
Claim denied as provider Non – Par – contd…
Steps to resolve :
1. Check whether the service is an ‘Emergency Service’ [POS Code – 23]. If Yes, need to call the insurance for
reprocessing the claim.
2. If Pt’s plan is HMO and Provider is Non-Par, denial is right.
If PPO/POS, need to call the insurance for reprocessing the claim.
1. Check whether the rendering provider PIN# is updated in the billing software or previous notes. If yes, check
whether the validity of the PIN# is available. If available and is valid, need to call the insurance and request to
reprocess the claim.
2. If PIN has expired, need to call the insurance for verifying the provider contract period.
3. If there is a provider contract period and the DOS falls within the contract period, need to call the insurance and
request to reprocess the claim.
4. If the DOS falls out of the contract period or the provider was never contracted with the insurance, need to check
any recent claims which got paid to the provider as per contract. If available, need to request insurance to
reprocess the claim.
5. If no such paid claims, suggest to bill patient.

Note: This scenario can be worked upon without calling. We need to call the insurance only when we want to
reprocess the claim
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Claim Denied As Provider Non Par
EOB-13
Claim denied as non covered service
Meaning: The patient has taken treatment which is not covered by the insurance.

Claim Adjustment and Remark Codes:

CO96 Non-covered charge(s) as per provider’s contract
PR96 Non-covered charge(s) as per patient’s plan

Reasons:
1) The service is not payable as per the patient’s plan.
2) The service is not payable as per the provider’s contract.

Steps to resolve :
1) Check whether the service is not payable under the patient’s plan or the provider’s contract.
2) Check for any previous paid claims for the same patient, same procedure/diagnosis, by the
same insurance.
I. If Yes, need to call the insurance and request to reprocess the claim.
II. If No:
a) For Non-covered charges as per patient’s plan – suggest to bill patient (Check for Sec Ins before billing Pt)
b) For Non-covered charges as per provider’s contract – raise client review. (Possible Appeal or Write off)
Note: Sometimes the service could be non covered because of the Diagnosis. Hence check both Dx and Px for this
denial.
Note: This scenario can be worked upon without calling. We need to call the insurance only when we want to reprocess the
Claim denied as Non Covered charges/Service
EOB - 14
EOB - 15
Claim denied as diagnosis code inconsistent with CPT
Meaning: The treatment given to the patient is not related to the condition diagnosed on the patient.

Claim Adjustment and Remark Codes:

CO11 The diagnosis is inconsistent with the procedure.

Reasons:
1) The diagnosis code (or) procedure code have been entered incorrectly at the time of Charge Creation .
2) The diagnosis code (or) procedure code have been coded incorrectly .

Steps to resolve :
1) Check whether the codes entered in the billing software are as mentioned in the charge sheet/charge ticket
2) If any incorrect entries, correct the same and send a corrected claim.
3) If all the entries are correct, check for any previous paid claims for the same patient, same procedure, same
provider by the same insurance.
a. If Yes, need to call the insurance and request to reprocess the claim.
b. If No, raise Coding review request.

Note:
This scenario can be worked upon without calling.
We need to call the insurance only when we want to reprocess the claim.
Claim denied as Diagnosis Inconsistent with Procedure Code
EOB - 16
Claim denied as need primary EOB

Meaning: The insurance billed is the secondary insurance (They need Pri EOB). Some other insurance is primary.

Claim Adjustment and Remark Codes:

CO22 This care may be covered by another payer per coordination of benefits.

Reasons:
1. The patient has changed the COB information but has not updated the provider .
2. The secondary insurance has been incorrectly updated as primary in the billing software.
3. The patient has updated the COB form with the incorrect primary and secondary details.
4. We billed Secondary without Primary EOB

1 of 2
Claim denied as need primary EOB (contd…)
Steps to resolve :
1. Check whether the COB information has been updated in the billing software as per the COB form
2. If the COB information has been updated incorrectly in the billing software, update the information as per COB form.
Verify the eligibility on DOS with the updated primary insurance carrier and if eligible, file the claim to them.
3. If Primary Insurance issues this denial, need to call the insurance and verify which is the primary insurance as per their
records and since when. Is their COB detail is updated.
4. If there is no change in primary insurance details for the DOS, request the rep to reprocess the claim.
5. If Secondary Insurance issues this denial, need to verify the Pri details and Appeal to Sec with Pri Eob
6. Need to check for any recent claims paid to validate the denial.
7. If the Pri gives the denial and we are unable to get the more details on which ins is Primary as per their records, bill the
patient (so they will update provider with correct insurance details)

Note: This scenario can be worked upon without calling.

• We need to call the insurance only when we want to reprocess the claim (or) the eligibility details are not available
through the other sources like insurance website, previous notes. 2 of 2
Claim Denied For The Primary EOB/Claim Denied as Care
Covered by Another Payer

APPEAL
EOB - 17
Claim denied as primary paid maximum
Meaning: The Primary insurance has paid more than secondary allowable amount.

Claim Adjustment and Remark Codes:

CO23 The impact of prior payer(s) adjudication including payments and/or adjustments.

Reasons:
This denial would be received only from a secondary payer for the following reasons:
1. The allowed amount of the secondary insurance would be very less for a specified procedure.
2. The primary insurance would have a higher paid amount than the Secondary’s Allowable

Steps to resolve :
1. Check if the insurance is Primary or Secondary, if it’s from Primary payer then patient need to update COB information
to the Payor.
2. Compare the secondary allowed amount from Secondary EOB with the primary paid amount from the primary EOB.

Case1: Primary paid amount is more than secondary allowable amount.

Description Primary Insurance Secondary insurance

Allowed Amount $452.00 $405.00 Denial is accurate. Need to work as per
Paid Amount $425.00 $00.00 client instructions (W/O Claim)
Patient Responsibility $27.00 $00.00
1 of 2
Claim denied as primary paid maximum (contd…)
Case 2: Primary paid is less than secondary allowable amount.

In-Correct Denial Primary Insurance Secondary insurance (Reprocess Claim) Denial is invalid. Need to
Allowed Amount $452.00 $452.00
Paid Amount $425.00 $27.00 call insurance and request
Patient Responsibility $27.00 $00.00 to reprocess.

Case 3: Primary paid is equal to secondary allowable amount.

In-Correct Denial Primary Insurance Secondary insurance (Reprocess Claim) Denial is accurate. Need to
Allowed Amount $452.00 $425.00
Paid Amount $425.00 $0.00
work as per client
Patient Responsibility $27.00 $00.00 instructions. (Write Off
Claim)

Note: This scenario can be worked upon without calling.

We need to call the insurance only when we want to reprocess the claim

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Claim Denied As Primary Paid More Than Secondary Allowed
amount
EOB-18
Claim denied as patient ineligible on DOS
Meaning: Patient did not have a valid coverage with the insurance on the submitted date(s) of service.

Claim Adjustment and Remark Codes:

PR26 Expenses incurred prior to coverage.
PR27 Expenses incurred after coverage terminated.

Reasons:
1. The patient's insurance coverage having been terminated prior to receiving the services.
2. The patient’s insurance policy included on the claim was not eligible for the date of service billed.
3. The patient’s eligibility on DOS was not verified before providing the treatment.
4. The patient’s insurance policy came into effect after the date of service

Steps to resolve :
1. Ensure you have a copy of the patient’s most recently issued insurance card copy.
2. Verify that the member ID# on the patient’s insurance card is the same member ID# that was entered on the patient
insurance setup screen.
3. Verify eligibility with the payer by Call or via online, if the patient is an eligible member, by collecting policy start and end
dates.
4. If patient’s benefits were not active for the date of service on the claim, check for other insurance, if not availbale, need to
bill patient.
Claim denied as patient ineligible on DOS (contd…)
Case 1: Insurance ABC denied claim Case 2: Insurance ABC denied claim
Date of Service 30 January 2016 Date of Service 30 January 2016
Policy Start Date 01 January 2016 Policy Start Date 01 January 2017
Policy End Date 31 December 2016 Policy End Date 31 December 2017

Case 1:
a) The denial is invalid, as date of service is within policy benefit period.
b) Need to call insurance and reprocess claim.

Case 2:
a) The denial is valid, as policy start from January 2017, where the date of service is in January 2016.
b) Need to verify, if the patient has any other insurance, file claim to that insurance after verifying eligibility
c) If not bill patient. Work as per client instructions.

Note: This scenario can be worked upon without calling.

We need to call the insurance only when we want to reprocess the claim or we are unable to check eligibility online.

2 of 2
Claim denied as Patient Ineligible for the Service/DOS
EOB - 19
Claim denied as maximum benefit exhausted
Meaning:
A benefit maximum is a limit on a covered service or supply. A service or supply may be limited by dollar amount,
duration, or number of visits.
The current insurance has already enough paid for this patient hence this insurance can’t pay more.
Patient coverage is active but insurance will not pay since the amount of maximum payable has been reached.
Some insurance companies limit the dollar amount they will pay per year for certain services, or they limit the quantity
of services eligible for coverage per year.

Claim Adjustment and Remark Codes:

CO119 Benefit maximum for this time period or occurrence has been reached.
N587 Policy benefits have been exhausted.
M13 Only one initial visit is covered per specialty per medical group.
N113 Only one initial visit is covered per physician, group practice or provider.
Reasons:
This denial can be for many reasons such as:
1. Annual Benefit Amount
2. Individual Lifetime Visits
3. Visit Limit / Dollar Limit
4. Maximum units exceeded for Medical Policy
1 of 2
Claim denied as maximum benefit exhausted (contd…)
Steps to resolve :

1. Check the benefit details online or on call – whether the benefit limit is visit based or amount based, the number of
visits or the maximum amount allowed.
2. Check if there is a balance in the benefit limit. If found request to reprocess the claim. If not, check the system to
see if the patient has any secondary insurance.
3. If there is no sufficient information provided in the system then go back to the original file in which the patient’s
insurance information was received and if there is a secondary insurance, the claim can be submitted to the
secondary insurance
4. If it does then re-file claims to that insurance.
5. If patient does not have any other insurance, bill the patient for allowed amount.

Note: This scenario can be worked upon without calling.

We need to call the insurance only to reprocess the claim or we are unable to check eligibility online.

2 of 2
Claim Denied As Benefits Exhausted / Services Maxed Out
EOB - 20
Claim denied as information submitted is Incorrect / Invalid
Meaning: Submitted information on claim form such as Provider, patient and insurance along with charges were
incomplete /invalid.

Claim Adjustment and Remark Codes:

CO 197
The authorization number is missing, invalid, or does not apply to the billed services or provider.
198
CO47 This diagnosis is not covered, missing, or are invalid.

CO58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

CO146 Diagnosis was invalid for the date(s) of service reported.

CO181 Procedure code was invalid on the date of service.
CO182 Procedure modifier was invalid on the date of service.
CO207 National Provider identifier - Invalid format
B18 This procedure code and modifier were invalid on the date of service.
M20 Missing/incomplete/invalid HCPCS.
Reasons:
Multiple reasons to deny claim as information submitted is incorrect / invalid.
Any information which is related to Provider, patient, insurance and charges billed on claim form should be accurate
with insurance data base.
Any of the information incomplete will lead to this denial and correspondence will help us to identify the same.
Claim denied as information submitted is Incorrect /
Invalid (contd…)
Steps to resolve :

These claims will be returned as unprocessed claims as rejections and corrections would be required. The below cases
are related to coding and need to be referred to the Coding team for a review. Alternative codes shall be assigned , if
needed.
Diagnosis code is missing, or are invalid: Billed diagnosis code is incorrect - Claim must have been filed with old
diagnosis code version. Claim must have filed without diagnosis codes. The current version of diagnosis codes is to be
used.
Procedure modifier was invalid on the date of service : This can mean the procedure code/modifier combination is
invalid or the procedure code or modifier is invalid. Check current CPT guidelines to verify the procedure, modifier
and/or the combination are valid for the date of service.
Invalid place of service - Treatment was deemed by the payer to have been rendered in an Example: A code described as
an outpatient service would not be valid if billed with an inpatient POS.
Procedure code was invalid on the date of service: Billed procedure code is incorrect / invalid for billed date of service -
Claim must have been filed with old procedure code which is invalid for date of service. The active procedure codes are
to be used as per current CPT guidelines.
Note: This scenario can be worked upon without calling.

2 of 2
Claim denied as invalid codes [CPT/ICD]/POS/Modifier
EOB - 21
Claim Processed & Paid to the provider

Meaning: The claim has been processed and paid to the provider. The check is in transit or it has been received at the
provider’s office, but the provider did not update the info to us yet.

Reasons:
The check would have been issued recently.
The check would have been received at the provider’s office but not posted
The check would have been received at the provider’s office but not encashed
The check would have been delivered to an incorrect address

Steps to resolve :
 Check whether the payment has been processed correctly by getting the allowed
amount, patient responsibility, paid amount from the EOB (if available) or with the
rep on call
Check whether all procedures were paid
 Check the mode of payment – Check or EFT from the EOB or with the rep on call
 If EFT – verify whether the payment was linked to the correct TIN of the provider with the rep
 If Check – Get to know when the check was issued , the check number and the check amount
(More steps on next slide)

1 of 2
Claim Processed & Paid to the provider (contd…)
Steps to resolve - continued:
 Verify whether the check has been sent to the correct ‘Pay To address’ either from the EOB or with the rep on call
 If Yes, then verify whether the check has been issued within 30 calender days from the current date. If so, wait for
the check to arrive.
 If the check has been issued more than 30 calender days from current date, ask the rep regarding the encashment
status.
 If the check has been encashed, ask the rep for a copy of the cancelled check (encashed chk)
 If the check has not been encashed, ask the rep to stop payment and issue a fresh check.
 If the check has been sent to an incorrect address, enquire the rep whether the check has been encashed.
 If encashed, ask the rep for a copy of the cancelled check (encashed check).
 If not encashed, fax a copy of W9 form to the insurance to update the pay to correct address
 Request the rep to stop payment of chk issued to the incorrect address and issue a fresh check to the correct pay
to address.

Note: This scenario can be worked upon without calling.

We need to call the insurance only when we do not have the EOB (or) when we do not have the encashment status of
the check (or) when we want the check to be cancelled and reissued.
2 of 2
Claim Processed & Paid To Provider
EOB - 22
Claim denied as duplicate
Meaning: The claim submitted has already been processed by the insurance. Similar service was performed for the same
patient on the same date by the same provider or multiple providers.

Claim Adjustment and Remark Codes:

CO18 Duplicate claim/service
N20 Service not payable with other service rendered on the same date
Your claim for a referred or purchased service cannot be paid because payment has already been made for this
N347
same service to another provider by a payment contractor representing the payer
M86 Service denied because payment already made for same/similar procedure within set time frame
CO-B20 Procedure/service was partially or fully furnished by another provider

Reasons:
1. The procedures on the claim could have been done more than once on the same DOS due to medical necessity either
by the same physician or two different physicians.
2. The claim could have been refiled as the original claim never reached the insurance and the original claim has been
received later on.
3. The service was performed by another provider, outside of your practice or group, on the same day as your service,
and payment has already been made to that provider.
4. The same claim was generated twice as the same charge sheet was processed by two different Charge Entry operators.
5. A corrected claim was sent.
1 of 2
Claim denied as duplicate (contd…)
Steps to resolve :
1. Check whether the billing software shows more than one claim for the same DOS.
2. If there is only one claim, check the claim filing history to know how many times the same claim was refiled.
3. If there was a refiling made need to get the status of the original submission.
4. If there were two claims, need to check if there are appropriate modifiers to differentiate the claims. If yes, need to
call the insurance and request them to reprocess the claim.
5. If there were no proper modifiers, then we need to move the claim for coding review to check whether there was a
medical necessity and get relevant modifiers coded.
6. If the denial was a corrected claim, need to call the insurance and mention the differences, request them to
reprocess.
7. If the claim was generated due to charge entry errors, suggest to write-off the denied claim.
8. The service was performed by another provider, outside of your practice or group- This can only be resolved by
contacting the insurance company. Ask the insurance company for their policy on appealing such a denial, each
insurance has their own process for doing this.

Note: This scenario can be worked upon without calling.

Calling is needed only when we need the claim to be reprocessed by the insurance.
2 of 2
Claim denied as duplicate
Claim denied as Pre-Existing Condition [PEC]
Meaning: : A pre-existing condition is a medical condition that started before a person's health insurance went in to
effect.
Before Yr 2014 some insurance policies would not cover expenses due to pre-existing conditions.

Claim Adjustment and Remark Codes:

PR51 These are non-covered services because this is a pre-existing condition.

Reasons:
1) Diagnosis codes matches with Pre-existing disease
2) Our Dos was within Waiting Period

Steps to resolve :

No More Pre-existing Conditions as of 2014

1) The PPACA (Patient Protection Affordable Care Act) – Obama Care, went one step further by prohibiting pre-existing
condition exclusions for all plans beginning January 1st 2014.
2) Check the policy coverage effective date – whether the date is on or after January 1, 2014. If yes, request the
insurance to reprocess the claim.
3) If no, need to call the insurance and confirm the pre-existing diagnosis code/waiting period.
1 of 2
Claim denied as Pre-Existing Condition [PEC] (contd…)
Diagnosis Codes
1. If diagnosis code is not related to pre-existing condition, request the insurance company to reprocess claim.
2. If it is related to the pre-existing condition, need to check the waiting period with the rep.

Waiting Period
It's the period of time specified in a health insurance policy which must pass before some or all of your health care
coverage can begin.
1. To understand better, need to know when policy becomes active and to reprocess claim
2. If treatment given after waiting period, request the insurance company to reprocess claim.
3. If not ,need to bill the patient.

Note: This scenario can be worked upon without calling.

Calling is needed only when we need the claim to be reprocessed by the insurance.

2 of 2
On-Call Analysisas&Pre-Existing
Claim denied Post-Call Actions
Condition [PEC]
Claim denied for Pre-existing condition

Dnd date

Dnd code

Verify the pt’s pre existing condition

Check if the dnd code is related to PEC or not

Dnd code is related to PEC Dnd code is not related to PEC

Update rep & request

Verify the waiting period
reprocess

Verify the policy effective date F/U date

Check if DOS falls within the waiting

Clm#, call ref#
period or not

DOS falls within waiting period DOS not within waiting period

Update rep & request

reprocess
Clm#, call ref#

F/U date

Suggest provider to Bill the patient

Clm#, call ref#

EOB - 23EOB
Sample
Claim denied as global procedure
Meaning: A global period is a period of time starting with a surgical procedure and ending some period of time after
the procedure. Many surgeries have a follow-up period during which charges for normal post-operative care are
bundled into the global surgery fee. The global surgical package is a single payment for all care associated with a
surgical procedure. The payment is based on three phases of a surgical procedure.
 Pre-operative evaluation.
 Intra-operative procedure.
 Postoperative care for either zero (0), ten (10), or ninety (90) days.

The follow-up procedure done during the global period is called a global procedure.

Claim Adjustment and Remark Codes:

N525 These services are not covered when performed within the global period of another service.
M144 Pre-/post-operative care payment is included in the allowance for the surgery/procedure.

Reasons:
1) The follow-up procedure was performed related to the surgery procedure
2) The follow-up procedure was performed during the global period

1 of 2
Claim denied as global procedure (contd…)
Steps to resolve :

1. Check whether there was any surgical procedure performed up to 90 calendar days prior to the follow-up procedure
DOS.
2. If No, need to call insurance and request to reprocess.
3. If Yes, need to get the global period for the surgery code.
4. Check whether the follow-up procedure code was performed within the global period.
5. If No, need to call insurance and request to reprocess.
6. If Yes, check whether the diagnosis codes billed with the surgery procedure and the follow-up procedure code are
matching.
7. If No, need to call insurance and request to reprocess.
8. If Yes, need to raise client review for further action.

Note:
This scenario can be worked upon without calling. Calling is needed only when we need the claim to be reprocessed by
the insurance.

2 of 2
Claim denied as Global

Get the denied date, denied procedure code,. Get diagnosis

code

Any surgical
No
procedure performed 90 days
before DOS?

Yes

Get the surgery procedure code, surgery diagnosis code, global period of surgery Request the rep to
procedure code. reprocess the claim.

Get the claim # Call ref#

DOS falls No
within global period?

Yes

Surgery No
diagnosis Code = Follow-up
diagnosis code ?

Yes

Raise client review.

Get claim#, call ref#
EOB - 24EOB
Sample
Claim denied for medical necessity
Meaning: Medical necessity is defined as accepted health care services and supplies provided by health care entities
appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable
standard of care.

1. Determinations of medical necessity must adhere to the standard of care that applies to the actual direct care and
treatment of the patient.
2. It must reflect the efficient and cost-effective application of patient care and be made in a concurrent review should
include discussions with the attending provider as to the current medical condition of the patient whenever possible.

Claim Adjustment and Remark Codes:

CO50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.
Payment denied/reduced because the payer deems the information submitted does not support this level of
CO57
service, this many services, this length of service, this dosage, or this day's supply.
Payment adjusted because the payer deems the information submitted does not support this
CO151
many/frequency of services.
This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in
N115
determining whether a particular item or service is covered.
1 of 2
Claim denied for medical necessity (contd…)
Reasons:
1. The treatment does not appear to meet medical necessity criteria
2. The treatment cannot be medically certified based on the information provided by the treating clinician, or the
treating clinician’s designated representative.
3. The procedure code is billed with an incompatible diagnosis
4. Payment purposes and the ICD-10 code(s) submitted is not covered under a Local or National Coverage determination
(LCD/NCD)

Steps to resolve :
1. NCD/LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary for the
diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part.
2. Refer to NCD/LCD and procedure to diagnosis lookup tool, to determine if a current and draft NCD/LCD exists for the
denied procedure code.
3. If the NCD/LCD exists for the procedure code, need to call the insurance and request to reprocess.
4. If the NCD/LCD does not exist, need to check if there are any previous paid claims with the same set of codes for the
same patient. If yes, need to call insurance and request to reprocess the claim.
5. If not, need to check with the insurance what are the documents acceptable as proof of Medical Necessity and send
out an appeal with the relevant documents.

Note: This scenario can be worked upon without calling. 2 of 2

Calling is needed only when we need the claim to be reprocessed by the insurance.
Claim denied for medical necessity
EOB - 25
Claim denied as Mutually Inclusive Proceduregics
Meaning: The payment of the procedure code denied is a part of the other procedure processed and paid.

Claim Adjustment and Remark Codes:

The benefit for this service is included in the payment/allowance for another
CO97
service/procedure that has already been adjudicated.

Reasons:
1. The procedure code denied is included in the other procedure code.
2. The procedure code denied cannot be done alone. It has to be done in combination with the other code
3. The denied procedure code which is a part of some other code is the ‘Component’ procedure code. The other
procedure code is the ‘Comprehensive Code’, as it includes another procedure code.

1 of 2
Claim denied as Mutually Inclusive Procedure (contd…)gics
Steps to resolve :

1. Need to identify the ‘Component procedure code’ [denied procedure code] from the EOB. The ‘Comprehensive
procedure code’ [the procedure code which includes the denied code] shall be identified from the billing software
or from the insurance rep on call.
2. Check the NCCI edits either through any of the coder tools or through the CCI Edit spread-sheets from CMS
website. This is done to identify if the denied procedure code has any coding conflict with the Comprehensive
procedure code.
3. If there is no coding conflict, call the insurance and request to reprocess the claim.
4. If there is a coding conflict, need to check whether a modifier can be used. If yes, need to raise a Coding review for
getting appropriate modifiers.
5. If a modifier cannot be used, then need to raise client review for further action.

Note: This scenario can be worked upon without calling.

Calling is needed only when we need the claim to be reprocessed by the insurance.

2 of 2
Claim Denied As Mutually Inclusive
EOB - 26
Provider Not Eligible To Perform The Service
Meaning: The provider has signed a contract with the insurance. Based on the contract, the
provider cannot provide the service.
Claim Adjustment and Remark Codes:
CO185 The rendering provider is not eligible to perform the service billed.

Reason(s):
1) The service is not covered under the contract with the insurance.
2) The NPI of the provider is incorrect.
Steps to resolve:
Refer Previous notes / correspondence / denials or other claims for the provider not eligible
to perform the service
 Review all claims for this provider with same CPT and DX combinations to see if any
were paid
 If any of the information is available, call the insurance and have them reprocessed.
 If there is no information available, place all the claims for the provider with same
CPT & DX combinations on hold and escalate to client.
Provider Not Eligible To Perform The Service
EOB - 27
 Denial related to Work Comp / Auto Related
Meaning: The patient is covered by a Work Comp or Auto Liability carrier. The claim has to be
filed to them first.

Claim Adjustment and Remark Codes:

PR19 This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
PR20 This injury/illness is covered by the liability carrier.
PR21 This injury/illness is the liability of the no-fault carrier.
Reason(s):
1) The insurance details could have been updated incorrectly
2) The patient would have provided an incorrect COB detail

Steps to resolve:
Check Previous notes / Insurance details for state Employment or Auto accident related insurances
Is there a claim number available in place of insurance ID
Review other DOS with same CPT/DX to ascertain if they were processed as medical or Injury related
Review patient chart to ascertain if the service pertains to Injury
Was the claim submitted to correct payor?
Is there is a note stating this is under litigation
 If any of the information is available above update the correct information in the claim append corrected claim
in block 19 and re-submit the claim with Medical records.
 Apply this action to all open claims of this patient with Same CPT/DX combination.
 If there is no information patient needs to be contacted for correct information.
Denial related to Work Comp / Auto Related
EOB - 28
Missing / Invalid / Incomplete Referring Provider Identification
Meaning: The referring physician details are missing on the claim form.
Claim Adjustment and Remark Codes:
COM68 Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification.

Reason(s):
1) The plan would not need the involvement of a referring physician.
2) The referring physician details would have been missed out while entering the details
Steps to resolve:
 Refer Previous notes / correspondence / denials or other claims,
 Check whether the plan is a HMO or an In-network POS.
 If no, request the insurance to reprocess the claim.
 If yes, check whether the detail has been missed out / entered incorrectly.
 If the information has been missed out / entered incorrectly, update the detail and send a corrected claim.
 If no referring physician information was available, check for any previous claims paid without the referring physician details
for the same patient, plan.
 If no previous paid claim details are available, place all the claims for the provider with same CPT & DX combinations on hold
and escalate to client.
This scenario needs calling only when the claim has to be sent for reprocessing.
Referring Physician Not Available / Missing On Claim Form
EOB - 29
Services not covered because the patient is enrolled in a hospice
Meaning: The service is done to the patient is hospice related

Claim Adjustment and Remark Codes:

COB9 Patient is enrolled in a Hospice.

Reason(s):
1) The Place of Service code is updated incorrectly.
2) The service performed is related to a hospice.

Steps to resolve:
Refer Previous notes / correspondence / denials or other claims,
Check whether the POS codes are entered correctly.
If yes, review all claims for this provider with same CPT and DX combinations to see if any were paid
 If any such claims have been paid, call the insurance and have the claim reprocessed.
If no previous paid claims, check if there are any hospice related modifiers [‘GV’ or ‘GW’].
If there are no hospice related modifiers, request the insurance to reprocess the claim.
If any hospice related modifier is found, raise a Coding Review request for getting the correct codes.
If there is any incorrect entry in POS codes, correct the same and submit as a corrected claim.

This scenario needs calling only when the claim has to be sent for reprocessing.
Services not covered because the patient is enrolled in a hospice

Get the denied date, denied procedure code from the EOB.

Check
in s/w if there are No Call insurance to reprocess the claim.
any hospice related modifiers
[GV/ GW] billed Get the claim # from EOB

Yes

Raise coding review to get suitable modifiers.

Get the claim # from EOB.

 Missing /Incomplete/ Rendering Provider Taxonomy
Meaning: The taxonomy [specialty] of the rendering provider is
missing / incomplete

Claim Adjustment and Remark Codes:

CON251 Missing/incomplete/invalid attending provider taxonomy.

Reason(s):
1) The taxonomy/specialty details of the rendering provider has not
been entered or entered incompletely.

Steps to resolve:
Refer Previous notes / correspondence / denials or other claims,
Review all claims for this provider with same CPT and DX combinations to see if any were paid with the same
taxonomy details.
 If any such claims have been paid, call the insurance and have the claim reprocessed.
If no previous paid claims, escalate the case to the client for further action.

This scenario does not need calling.

Why AR? - Revision

Balance outstanding with insurance

The payment is not received within 45 days

Claim not submitted

Correspondence received

Claim stuck in clearing house

Partial payment received from insurance

Payment received and not posted

 Prioritizing work orders
Work Order – a list of claims outstanding for payment follow-up.

 One of the most important parts in accounts receivable follow-up is finding a prioritization flow for the day.
 The key to deciding which claim needs to be followed first is based on how far past due they are.
 Sometimes it is tempting to make a phone call to those that have the largest amount past due, but those claims that you
haven’t heard anything from should be the most concerning.
 Those claims that have crossed the 30 day line deserve a follow-up
 The best strategy is by putting claims into aging buckets on which claim is the latest past due for 31-60 days, 61-90 days,
91-120 days and 121 plus days.
 Work your way backward by reaching out to the claims that are in the 121 plus days bucket.
 The order of priority for work orders is,
 Priority 1 – Claims in the oldest ageing bucket
 Priority 2 – Claims with high dollar amounts
 Priority 3 - Claims filed to the same insurance
 By working down through a list, you are most likely to reach out to the most claims.
 You can continue down your list until each outstanding claim is touched.
 By working through an aging list, you can be sure to hit all claims, not just those that need the heat.
 This method helps you to track every outstanding claim.

CONFIDENTIAL
 Identifying trends and taking global actions
Trend – a denial pattern applicable for more than one claim / patient

Identifying trends:
A trend is identified when the same denial is received from a specified insurance on either,
 The same procedure code(s) or
 The diagnosis code(s) or
 The same rendering physician or
 The same modifier(s) or
 The same Place of service [POS code] or
 A combination of some (or) all of the above

Global Action:
 An action taken on one particular claim and could be applied for all other claims following the same trend.
Example: When a procedure code is denied as ‘Non-covered service’
as per patient’s plan. The action taken to resolve that claim, can be
used for all other claims billed to the same insurance with the same
procedure code, same plan.
Advantages of taking global actions:
 Helps to resolve more number of claims at a lesser time without calling.
 Serves as an alert or feedback for billing to avoid similar denials in
future.
CONFIDENTIAL
 Time management on calls
The way an associate utilizes his/her time on call decides the effectiveness of the follow-up. Below
mentioned are a few useful points,

1) Utilize the call hold time to perform pre-call analysis on the other accounts.
2) Any additional on-call analysis also can be performed during the hold time.
3) If anything needs to be referred from the sources like cheat-sheets, contract sheets, etc., it can be performed during the hold
time.
4) Review the billing software for such information, which may make the claim payable (if it is denied for some reason)
5) If following up on a fresh claim, look whether there are any entry errors which possibly may lead to a denial. If any such
identified, note down them so that they could be included in the documentation.
6) If a procedure has been denied by an insurance for a specified reason, review the billing software for similar such trends in
the other accounts.

CONFIDENTIAL
 Documentation – is important
* It plays an important role in an AR’s job

* It is imperative that each employee understands the proper way to document accounts.

* Determining what next steps should be taken on an account will depend upon how well the previous notes were
entered.

* If notations are not done properly, it will make understanding difficult.

* It may also be difficult to determine what we should do next.

* By reviewing the previous documentation and learning which screens to view and analyze for claim status, by reviewing
payments and adjustments, will help us determine the correct way to achieve account resolution and quality work.

CONFIDENTIAL
 Guidelines for Documentation
 Make It a habit to document each call immediately.

 Document in the order it has occurred.

 Don’t leave out important details such as dates, amounts, or the person with whom you spoke.

 Take the time to document notes correctly.

 Make sure your notes will be easily understood by anyone else who may have access to the account.

 Don’t leave your co-workers in the fog.

CONFIDENTIAL
If it’s not in your notes,
it didn’t happen…….!

CONFIDENTIAL
Components of documentation

* Insurance company’s name & tel # - extn #

* Insurance Rep’s name

* Title of the status

* Dates of relevance

* Information collected in a systematic order

* Actions taken / recommended

* Claim / call ref #

CONFIDENTIAL
 Sample Documentation
Per review of EOB from Aetna dated 01/23/2016, the CPT 88305 has been
denied as “Payment already made for same/similar procedure within set
time frame“ on 01/18/2016. As per the billing software it has been billed
with the diagnosis code K62.89. The same CPT has been billed on the same
DOS once again with a different diagnosis code C18.4. Both the CPTs were
not paid. Called Aetna @ 888-632-3862. Spoke with Cindy P. Indicated the
differences between both the line items. Rep said that they wanted the
medical records to be sent to them in this regard. Therefore need to mail
the records to Aetna Provider Resolution Team PO Box 14020 Lexington, KY
40512 within 60days. The records shall be faxed to 859-455-8650
[Attention: Provider Resolution Team]. Claim# A87564132. Call ref#
85426789.

CONFIDENTIAL
Common Abbreviations
* Do not use common abbreviations or acronyms when documenting an account.
* It is extremely important to that the documentation must be clear enough for
ANYONE to understand it.
* If in doubt about how to abbreviate something, a good rule is to take out the vowels.
* If still unsure, type the word out.
Examples
 Clm - Claim,
 Pt – Patient
 DOD – Date of denial
 DOS – Date of service
 Pd - Paid
 S/W – Software
 F/U – Follow-up

CONFIDENTIAL
Don’ts

* Never, Never, Never include financial information in a patient’s account

notes (credit card numbers….. etc., ).

* This is considered as Protected Health Information under HIPAA

guidelines and is a violation of the patient’s privacy.

CONFIDENTIAL
Denial Letter
Refund Letter
Denial Letter Format
Refund Letter
Corrected Claims & Appeals
Sending Corrected Claims
Sending Appeals
Medicare Appeals Process
Commercial Appeals Process
If you decide to appeal
If you decide to appeal, ask your doctor, health care provider, or supplier
for any information that may help your case. See your plan materials, or
contact your plan for details about your appeal rights. Generally, you can
find your plan's contact information on your plan membership card.

The process includes:

1. Reconsiderations: Formal reviews of claims reimbursements or coding
decisions, or claims that require reprocessing.
2. Level 1 appeals: Requests to change a reconsideration decision, an
initial utilization review decision, or an initial claim decision based on
medical necessity or experimental/investigational coverage criteria.
3. Level 2 appeals: Requests to change a Level 1 appeal decision.
 Resolving the dispute
we'll need send below information while sending an appeal:
 The reasons why you disagree with our decision
 A copy of the denial letter or Explanation of Benefits letter
 The original claim
 Documents that support your POS (for example, medical records and
office notes etc..,)

Conclusion
Please make sure below before sending appeals such as:
1. To whose’ s attention it should be Ex: Attention Claims, Claims dispute
etc..,
2. Any Fax # or mailing address for paper claims.