IMPORTANT DENIED QUESTIONS NEED TO BE ASK BY AR TO RESOLVE THE CLAIMS

 IMPORTANT QUESTIONS NEED TO BE ASK BY AR TO RESOLVE THE CLAIMS

1. Claim Not on File: -

* Effective date of the policy?

* Is policy active or not at the time of service?

* Filing Limit of the Insurance?

* Is they accept FAX or not, if yes then ask FAX# and Attention?

* Is They are the primary or secondary?

* Claim submission address?

* If claim submit through Electronically then need to check Emdeon & EDI report?

2. Paid Claims: -

* Allowed and Paid amt?

* Is there any patient responsibility?

* Cheque issued date.

* Cheque#?

* Has it been cashed or not, if yes then what was the cashed date?

* Is it bulk or single cheque, if bulk what was the amt?

* Verify pay to address?

* Process in network or out of network (If the claim was processed out of network need to argue

why this Claim processed out of network if we are participated then why)?

* Clam #?

* If the cheque was cashed long day ago and yet the payment was not posted need to ask for

duplicate EOB to be faxed or mailed to us on our respective email ID or fax#.

* If the payment was made partially or low need to argue with the rep because the payment was too

low?

* If the cheque was sent to the wrong address, then need to ask to rep to put Track# for this claim

and take TRACKING#.

3. Untimely Filing: -

* Denial date?

* Claim read date for the first time.

* Filing limit?

* Check SQL med whether we first billed this claim under filling limit or not?

if this was not actual late filling then please ask appeal limit and appeal address?

* Need to ask appeal limit and address and with whom attention this appeal letter should be sent?

* And also ask whether they appeal through fax or not, if yes ask FAX#?

* And also attach e.med.On proof that show's we billed within filling limit with appeal cover letter.

* If this was actual late filling mention in the notes first billed date and need to write-off the

claim.

4. Member not eligible: -

* Denial date?

* Clam#?

* Effective and termination date?

* Cross verify is patient is really not eligible.

* Ask is there any other policy in which member enrolled at the time of service?

(If yes ask the Policy ID#, name of the insurance and in which plan he is in?)

* Check documents and epacts for any other insurance listed or not, if any call to that insurance

Ask about the eligibility of the patient?

* If not call patient for the coverage information, if the patient is not having other insurance, then

bill to the patient with proper notes.

5. Pre-existing conditions:-

* Denial date or pending date?

* Clam#?

* Effective date?

* Waiting Period?

* When the last Questionnaire sent to the patient or Provider?

* Request to send Questionnaire once more?

* If the questionnaire was sent to the patient more than 30 days before. Hence need to bill

Patient with proper notes. If it was sent to the provider need to mention in the notes correctly.

6. Maximum Benefit Met or Reached: -

* Denial date?

* Clam#?

* What was max benefit limit? Is it terms of services or in $ amt.

* In terms of services, when did they paid last for those services and if in terms of $ what

Was the limit?

* In case of MCR checked ABN (Advance beneficiary form) Form in document’s if found signed

by the patient bill the patient. If not found mention in the notes account place to pending write off

and for other insurance no need to check ABN just billed patient with proper notes.

7. No Pre-authorization and NO Authorization Denial:-

* Denial date?

* Clam#?

Pre-auth- take before the DOS

* Check your system if auth is available than provide it to rep and ask them to reprocess the claim

* If the auth is not available in our system the ask the rep if this service really need the auth if yes than

ask is someone from our office ever initiated the auth request if yes than ask them to take that auth and

reprocess the claim.

* If auth was never obtained by office ever than ask them if we can request the retro auth now for this

claim or not if yes then initiate the request if not than ask how we can submit appeal to them.

8. Service not covered: -

* Denial date?

* Clam#?

* Ask this service not covered under patient or provider plan. It   is in patient plan check

documents and epacts, if nothing found bill patient.

* If it is in provider plan need to mention in the notes correctly and place to pending write off.

* If claim processed for Non-par Carrier, then place to pending write off, whether denied under

patient plan or provider plan.

9. No Referral:-

* Denial date?

* Clam#?

* Need to check documents and system whether we have referral# or not.

* If found cross verify with the rep and sent this claim back for reprocess.

* Ask for Reference# from rep. and duration of processing this claim?

* If Referral not found billed the patient with proper notes for Participating provider and non-par

place to write off.

10. Bundled, Inclusive, Incidental, Subset, Add-on code and Component Procedure: -

* Denial date?

* Clam#?

* Primary Procedure?

* Mention in the notes whether its paid or not.

* If it's not paid then ask rep why the Primary CPT not paid?

* If its paid ask details for the payment and mention in the notes for Primary procedure?

* If it in Bundle list need check Encoder-pro if both CPT can bill together then appeal to

insurance with Encoder pro screen shot and as per encoder pro if both CPT and cannot billed

together but modifier allowed then follow the protocol, and also check bundle list if Cpt found

then place to write off.

* Primary CPT amt should be higher.

11. Invalid DX or CPT:-

* Denial date?

* Clam#?

* Why this CPT or DX is invalid?

* If we can rebill this claim with addition of modifier. Need to add and rebilled again with

Proper notes.

* And also mention the DX code listed in system.

* And if we billed with Incorrect DX then refer to billing Dept.

12. Student Info:-

* Denial date?

* Clam#?

* Last Questionnaire sent to the patient on which date?

* Request to send Questionnaire once more?

* If the Questionnaire sent to the patient more than 30 days ago. Need to bill patient with proper

notes.

13. Duplicate or previously processed or denied claims: -

* Denial date?

* Clam#?

* Need to check whether this claim was billed twice whether with the same DX code, if bill

with same DX need to review medical records, if as medical records show's service performed, then need to follow the protocol.

* If it is Duplicate claim need to take original status of that CPT.

* If that CPT was genuinely billed twice need to ask where we can bill this claim again with

modifier then place in pending write off.

14. Applied to patient’s deductible: -

* Clam processed date.

* Clam#?

* How much they allowed and out of this how much applied to the patient?

* How do they process this claim in network or out of network?

* If processed in network need to see is there any secondary insurance, if found need to verify

Eligibility and transfer to the secondary.

* If there is no other insurance and processed in network need to bill patient with proper notes.

* If processed out of network argue with the rep if we are participated why claim processed out

* Of network and try to reprocess the claim and take ref# and duration of processing.

NOTE: - In case of GHI they never and ever pay deductible after the primary insurance.

15. Claim in process: -

* Clam read date?

* Clam#?

* How much time it will take?

* If the claim was still in process from a long day back need to argue with the rep.

16. Payment to Patient: - For (Non-Par)

* Clam processed date.

* Need to check Whom they paid? Patient or Provider.

* If claim paid to provider, then work as per the protocol, and if paid to patient then need to send

firstly, payment to patient letter to patient with EOB website that should be convert into .pdf

format.

And non-covered chargers should be adjusted in slimed. And for second time and we didn't get payment then send escalation letter to patient with EOB website once again in same format as we send first letter.

 And third time bill patient only amount that was paid by insurance to patient and rest amount should be adjust.

* Clam#?

17. Non-Par Provider

* Denial date?

* Clam#?

* Check cheat list we are non-par then write off other appeal or reprocess the claim

* Ttake ref# and duration?

18. Invalid UPIN#:-

* Denial date?

* Clm#?

* Find Upin# in nynpi.com or in Parcs, if found serarched UPIN# or by Provider Name from

Ecare.com If UPIN# found valid need to mention in the notes correctly.

19. Need Medical Records or Invoices: -

* Denial d

* Clam#?

* Ask which kind of Medical Records they need?

* For Invoices ask whether they accept faxes, if they accept Fax, need to ask Fax# and the

attention?and if they want medical records verify address and send.

20. Appeal Denied: -

* Denial date?

* Clam#?

* Need to mention why we appeal for this claim.

* Cross verify is the appeal denied correctly then place to write off, if not then argue with the and

reprocess the claim or appeal.