1.

UNABLE TO IDENTIFY PATIENT

MEMBER ID

Patient is Identified Patient is not Identified

SEARCH WITH PATIENT NAME, DATE OF BIRTH, SSN#, ADDRESS, PH #

Claim Status

Patient is Identified Patient is not Identified

Claim # & Ref #
Collect the correct ( Ref )
Member ID PC: Check in Software does
PC: Work Accordingly patient has any other
Claim Status insurance

Claim # & Ref #

YES NO

PC: Update the collected

Call & BEV Bill Patient
Member ID & Work
Accordingly
Active/Primary In-Active/Secondary

Bill Insurance Bill Patient COB

 2. NO CLAIM ON FILE
May i know the Policy Effective Date [ Start-End]

Patient is active on Date of Service Patient is not active on Date of Service

Verify does patient has any other insurance

May I know the Timely Filing Limit

YES NO
Claim within TFL Claim Passed TFL
Collect Insurance Ref #
May I know the Mailing Address Verify the Mailing Details
Address PC: Check in
Ref #
Software does
patient has any
Correct Address In-Correct Address Ref # other insurance
PC: CALL & BEV
PC: Verify for YES NO
Collect the correct mailing proof of TFL Active/Primary In-Active/Sec
Ref # address
Bill Insurance Bill Patient COB Bill
PC: CALL
Patient
PC: Resubmit Ref # & BEV
Found Not Found
PC: Update the Active/Primary In-Active/Sec
correct mailing
address & Resubmit Attach the Review & Bill Insurance Bill Patient
the claim proof & Write off
resubmit
 3. CLAIM IN PROCESS
May i know the claim Received Date

May i know the Normal Processing Time [Turn Around Time ]

Within the Turn Around Time Passed the Turn Around Time

Collect the follow-up date Ask the reason for delay in Processing

Claim # & Ref # Request to Speed up the process

Collect follow-up date

PC: Need to follow-up
& collect the details Claim # & Ref #

PC: Need to follow-up

 4. Paid to Providers
May i know the Processed Date

May i know Allowed Amount, Paid Amount, Patient Responsibility [ co-pay, co-
insurance, deductible ]
May i know the mode of payment

Cheque Electronic Fund Transfer

Cheque #, Date, Amount [ Single/Bulk ] EFT #, Date, Amount

Verify the Cheque mailing Address Req EOB [ 30 Days ]

Correct Address In-Correct Address Claim # & Ref #

Check whether cheque is Stop payment & review New
cash or not cashed Cheque for correct address PC: Suggest payment
Cashed Not Cashed posting team to post
Claim # & Ref #
Req EOB Req cheque Tracer
payment
PC: Update W-9 form
Claim # & Ref # Claim # & Ref #
PC: Suggest payment posting PC: Needs to follow up
team to post payment
 5. Paid to Patient
May i know the Processed Date

May i know Allowed Amount, Paid Amount, Patient Responsibility [ co-pay, co-insurance, deductible ]

May i know the reason for payment to patient

AOB Not Signed Provider Non Participant

Check in Software for Block # 27 Check in Software for PIN #

whether it is accepted or not
PIN # Found PIN # Not Found
Accepted Not Accepted

Update the same & Update the same & Req EOB
Req EOB
send claim back for send claim back
reprocess reprocess Claim # & Ref #
Claim # & Ref #
Collect & Need follow up
Collect & Need follow up date
date PC: Bill Patient PC: Bill Patient

Claim # & Ref #

Claim # & Ref #

PC: Needs to follow up

PC: Needs to follow up
 6. Claim Denied as Policy inactive / Termed
Denial Date

May i know the policy effective date [ Start – End ]

Patient is active on Date of Service Patient is not active on Date of Service

Update the same & send Verify does patient has any other insurance
claim back for reprocess

YES NO
Collect the follow up date
Collect the Details Claim# & Ref #

Claim # & Ref # Claim # & Ref # PC: Check in Software

does patient has any
other insurance
PC: CALL & BEV
PC: Needs to follow up
Active/Primary In-Active/Sec YES NO

Bill Insurance Bill Patient CALL & BEV Bill Patient

Active/Primary In-Active/Sec
Bill Insurance Bill Patient
 7. Claim Denied as Untimely Filing Limit/Passed Timely Filing Limit
Received Date

Denial Date

May i know the Timely Filing Limit

Claim Received within the TFL Passed the TFL

Appeal limit, Time, Address,

Update the same & send claim back
Fax # attention to
for reprocess
Req EOB
Collect the follow up date
Claim # & Ref #
Claim # & Ref # PC: Check in Software for proof of
Timely Filing Limit

PC: Needs to follow up

YES NO
Attach the proof &
Review & Write off
resubmit/appeal
 8. Claim Denied as need prior Authorization #
Received Date
Denial Date

Denial Code
Check in Software whether treatment is related to Emergency / Non-Emergency

Emergency Non-Emergency

Check in CMS1500 Block #23

Update the same & send claim back
for Authorization #
for reprocess
Authorization # found Authorization # not found
Collect the follow up date
Update the same & send Appeal limit, Time,
claim back for reprocess Address,
Claim # & Ref # Fax # attention to
Collect the follow up date
PC: Needs to follow up Req EOB
Claim # & Ref #
Claim # & Ref #
PC: Needs to follow up PC: Appeal with Authorization
 9. Claim Denied as not Medically Necessary
Received Date

Denial Date

Denial Code

Verify with insurance representative, Can we submit Medical

Record/Patient Care Reports to prove it is Medically Necessary

Collect Appeal limit, Time, Address, Fax # attention to

Req EOB

Claim # & Ref #

PC: Needs to Appeal with Patient

Care Reports/ Medical Record
 10. Claim denied as Missing/Invalid information
Denial Date

Denied Code

Verify with representative whether information is Missing/Invalid

Information is Missing Information is Invalid

Check in Software for Valid Information

Check in Software for Missing Information

Valid Information Found Not Found

Found Not Found

Update the same & Update the same & Appeal limit, Time, Address,
Appeal limit, Time, Address,
send claim back for send claim back Fax # attention to
Fax # attention to
reprocess reprocess
Req EOB
Req EOB Collect follow up date
Collect follow up date
Claim # & Ref #
Claim # & Ref #
Claim # & Ref #
Claim # & Ref # PC: Appeal for Invalid
PC: Appeal for Missing blocks to update
information to update
PC: Needs to follow up
PC: Needs to follow up
 11. Claim denied as Need Additional Information
Denial Date

Denied Code

Verify from whom & what information is required

Patient
Provider

Have you sent any letter

Check in Software for Additional Information

How many letter were sent

Found Not Found

Update the same & When was last letter sent

Have you sent any letter
send claim back for
reprocess Req EOB
How many letter were sent

When was last letter sent

Collect follow up date Claim # & Ref #
Appeal limit, Time, Address,
Fax # attention to PC: Bill Patient
Claim # & Ref #

Req EOB
PC: Needs to follow up
PC: Appeal for Additional
Claim # & Ref # information to update
 12. Claim denied as Non-Covered Service
Denial Date

Denied Code

May I know as per who’s plan it is Non-Covered

Patient
Provider

Req EOB
Check in Software whether same service was paid previously or not

Claim # & Ref #

Was paid previously Was not paid previously
PC: Check in software does
Update the same & patient has secondary
Appeal limit, Time, Address,
send claim back for insurance
Fax # attention to
reprocess

Req EOB YES NO

Collect follow up date

Claim # & Ref # CALL & BEV Bill Patient

Claim # & Ref #
PC: Needs to appeal the
claim
Active/Primary In-Active/Sec
PC: Needs to follow up
Bill with Primary EOB Bill Patient
 13. Claim Denied as Procedure code is inconsistent with Diagnosis Code
Denial Date

Denial Code

Verify in ENCODER PRO whether Diagnosis code is consistent with Procedure code or not

Diagnosis code is consistent with Diagnosis code is inconsistent

procedure code with procedure code

Update the same & send claim back Appeal limit, Time, Address,
for reprocess Fax # attention to

Collect the follow up date Req EOB

Claim # & Ref # Claim # & Ref #

PC: Needs to follow up PC: Coding Review

 14. Claim Denied as Need Primary EOB/Other Insurance

Denial Date

Verify in software whether you called primary insurance or secondary insurance

Called insurance is Primary Called insurance is secondary

Collect the details of Primary insurance Claim # & Ref #

Claim # & Ref # PC: Attach Primary

EOB & Submit
claim to secondary
PC: CALL & BEV

Active/Primary In-Active/Sec

Bill Insurance Bill Patient for COB

 15. Claim Denied as duplicate
Denial Date

Denial Code

Verify in software whether Date of Service, Place of service, Procedure, Diagnosis, Modifier,
Primary care Physician, Time is same or different

Found everything to be same Found to be different

Collect the original claim status & Update the uniqueness & send
Claim # claim back for reprocess

Claim # & Ref #

Collect the follow up date

PC: Void the duplicate claim &

work accordingly to original Claim # & Ref #
claim
PC: Needs to follow up
 16. Claim Denied as Primary Paid Maximum
Denial Date

Denial Code

Verify with representative what would be the secondary allowed amount

Primary paid more/equal than Primary paid less than

secondary allowed amount secondary allowed amount

Verify with representative can we bill Update the same & send claim
patient back for reprocess

YES NO Collect the follow up date

Claim # & Ref # Claim # & Ref # Claim # & Ref #

PC: Bill Patient PC: Review & write off PC: Needs to follow up
 17. Claim Processed towards deductible
Processed Date

Allowed amount & Deductible [ collect balance details ]

Verify whether it is In/Out of network deductible

Verify whether it is Annual/Life time deductible

Verify what is total deductible amount

Verify what is total deductible paid

Req EOB
PC: Check in software for
secondary insurance
Claim # & Ref #

YES NO

CALL & BEV Bill Patient

Active/Primary In-Active/Sec

Bill with Primary EOB Bill Patient

 18. Claim processed towards Offset
Processed Date

Allowed Amount & Offset amount

Allowed amount & Offset is same Allowed amount & Offset is different

Collect the details of Remaining amount

Collect Offset Trip #, Account #, Date of service,
Billed Amount, Allowed Amount, Paid amount,
Patient Responsibility, Cheque # / EFT details Collect Offset Trip #, Account #, Date of service,
Billed Amount, Allowed Amount, Paid amount,
Patient Responsibility, Cheque # / EFT details
Claim #

Claim #
Claim # & Ref #

Claim # & Ref #

PC: Send for payment posting
team to review & adjust
PC: Send for payment posting
team to review & adjust