AR SCENARIO’S

AR Scenario’s
• Basically AR scenario’s are segregated in 3 levels
• Non Denials
• Patient Denials
• Provider Denials

Non Denials •
•
Claim not on file
Rejections in Clearing House
• Claim in process
• Claim paid
• Claim paid to patient
• Patient Responsibility claims
 Claim not on file
Pre Call Analysis On Call Analysis Post Call Action

• Check whether claim was

billed out from System either
electronically or paper. • Need to check patient
• If claim was submitted eligibility
electronically whether it by • Mailing Address/Payer ID#/
passed from clearing house or Fax# if there is any chances to
not? submit the claim immediately
• If there is a rejection need to • TFL information
fix the rejection from clearing • Need to submit the claim via
house paper/clearing house/ fax
**Note: Even after 2nd follow up
• If no rejection found need to the insurance is not receiving the
check whether claim billed to claim from provider need to do
correct payer ID# or not? analysis from the clearing house
• If claim was submitted paper how many claims are billing to
whether the claim was send to this payer.
correct mailing address or
not?
• If every things looks fine need
to take call.
 No claim on file

Check the policy coverage

Yes No
DOS lies between effective
and termed date

Check Is there any other active

Check DOS lies within the TFL
policy for the patient on DOS?

No
Yes Yes No

Submit the claim Via Capture the patient

Submit the claim Via
mailing address, Payer policy ID, coverage
mailing address, Payer Bill the patient
ID and Fax#? and submit the
ID and Fax# with POTFL
claim
 Clearing House Rejections
Pre Call Analysis On Call Analysis Post Call Action

• If rejection found in clearing

house need to understand
whether it is front end rejections
(Failed claims), Back end
rejections (Payer end rejections),
Hold claims.
• 99% not required to call as the
• All failed claims can be fixed rejections can be fixed
internally these are missing few internally • Need to fix the rejections and
information on CMS 1500. release the claim from
• 1% rejections needs to fix clearing house
• Hold claims nothing but giving over the call with payer if you
an information if we release didn’t understand the
there is a chance of getting
rejection reasons
denial/rejection

• Payer end rejections – Need to

understand the rejection reason
from payer, sometimes it can be
fix internally or need to call and
fix
 Clearing House Rejections

Hold Claims Failed Claims Payer end rejections

Missing information on CMS

As per rules and updates of 1500 or incorrect billing
Claim routed incorrect payer
CCPC the claims will be sitting Ex: Missing resubmission code
ID, incorrect group# as per
in clearing house on corrected claims, adding in
payer data base
appropriate character in id#
or patient name, etc..
 Claim in process
Pre Call Analysis On Call Analysis Post Call Action

• Check whether claim was

billed out from System either
electronically or paper.
• If claim was submitted • Need to know the TAT to
electronically whether it by process the claim.
passed from clearing house or • Whether payer is looking for
• Need to follow up after the
not? some additional information
TAT if the claim was not paid
• If no rejection found Check in from provider/patient to
web portal whether the claim process the claim.
processed or still in pending
• If claim was crosses 30 days
from submission date, Need to
call and check why the claim
was still in pending
 Claim in process

When did you receive the

claim?

No
What is the normal
processing time or TAT?
May I have the reason for
delay?

Yes Calculate TAT from Other Reasons

received date and check if (Backlog)
is it within the TAT?

Need to FU after TAT if it

was not paid
Information
Any Information or
requested from
documents requested from
patient
provider

Yes Have you No

What
sent letter to
documents/info requested?
patient?

May I have the address or When did you send the What
Fax# to send the letter? documents/info requested?
document/info?
 Claim Paid
Pre Call Analysis On Call Analysis Post Call Action

• Check in Web portal whether

claim was processed and paid • If claim was processed and
• If claim paid date with in the paid capture over the call.
30 days capture the check Capture the AA, BA & Patient
details and pull the EOB and responsibility along with
send it to posting team. check details • Send the EOB along with
• If claim paid date crosses 30 • If paid date crossed 30-45 check tracer to posting team.
days, needs to escalate to days, Need to request for
posting team to reconcile check tracer or sometimes
before posting the payments depends on the issue we need
as per EOB. to request new check.
• Depends on the response • Also request the COPY of EOB
need to call
 What are the allowed amount, paid Verify sum of PA and Patient
Claim Paid What is the processed & paid date? amount and patient responsibility (Coins, Responsibility(PTR) equals to AA, if not then
Deductible or Co-payment)? probe the rep and get the correct information

Check
Correct
May I have the check Was it Single check or Bulk Was payment done through
What is the check#?
mailing address? check#? Check or EFT/Credit Card?
Incorrect
EFT/Credit Card
Is the check
cashed? What is the Transaction ID?

Is the check
cashed?
Could you please Is payment cleared?
fax the EOB? If Not
then mail it Provide
correct check maili
ng address to rep
& ask to reissue
Could you please
new check
fax the EOB? If Not
then mail it
 Claim Paid to Patient
Pre Call Analysis On Call Analysis Post Call Action

• If claim was processed and

paid to patient. Verify whether
provider is OON or IN
• Check in Web portal whether • If Innetwork whether the CMS
claim was processed and paid 1500 submitted with • Send the statement to patient
• If claim paid to patient, check information of AOB. and request for payment.
whether the patient signed • Capture the AA, BA & Patient
AOB or not? responsibility along with
• Check the provider network check details
• Request the COPY of EOB if
the provide
 What are the allowed amount, paid Verify sum of PA and Patient
Claim Paid to patient What is the processed & paid date? amount and patient responsibility (Coins, Responsibility(PTR) equals to AA, if not then
Deductible or Co-payment)? probe the rep and get the correct information

Rebill the claim as corrected

AOB signed by patient AOB ISSUE
Why was the claim
claim paid to patient?

Need to FU after
30 days Provider is OON

AOB not signed by

patient In Network
Verify credentialing

Out of Network
Bill the Patient
Send back for
reprocess the Bill the Patient
claim to process as
in network
 Patient Responsibility
Pre Call Analysis On Call Analysis Post Call Action

• Check in Web portal whether • If claim was processed and

claim was processed and paid • Send the statement to patient
applies patient responsibility.
• If claim Processed towards and request for payment.
• What is the policy deductible
patient responsibility verify and how much was meet so far
the deductible/Coins/ Copay
 How much is the total deductible limit on the
Patient Responsibility May I have the processed date? What is the Allowed Amount(AA)?
policy?

If patient has met the deductible including this

Could you please fax the How much has patient met
claim/ Patient has not met the deductible
EOB? If not then mail it including this claim?
including this claim

If patient has already met the

deductible excluding this claim

Send the claim back for reprocessing since

What is the Turn patient has already met
Submit the claim
around his deductible excluding this claim?
to secondary/ Bill
time(TAT) for
Patient
reprocessing?