Top 12 AR & Denial Management Scenarios

ISSUES AND INSTRUCTIONS FOR TYPICAL AR AND DENIAL MANAGEMENT SCENRARIOS

Are you looking to outsource your healthcare back-office and administrative operations, but have a few reservations about outsourcing? Don't let that befall on you.

 At Flat world Solutions, we have been providing healthcare back-office support services for the last 18 years.

 We have a team of brilliant medical insurance support executives who can help you with re-submission and repair of denying claims.

 We have compiled a list of issues & actions in common AR & Denial Management scenarios. This will help you evaluate your process and find gaps.

Top 12 AR & Denial Management Scenarios

Scenario 1 - When Claims are not on Files

Key Points to Analyze Mail address of claim
Fax number
Doctor referral letter
Whom to fax the claim?
Enrolled eligibility status
Member not on the list
Date limit
Filing period
Verify ID and Group number
Questions to be Asked May I have the claims mailing address?
Could you please give me the fax number, and should I go ahead and fax the claim?
Should I check the eligibility status of the patient to verify the entitlement on the DOS
May I check with the payer to check the availability of the member?
Should I know the filing limit for this claim?

Scenario 2 - When Claim is in Process

Key Points to Analyze Claim received date
Claim Processing time
Technical Protocols to file a claim
Questions to be AskedCan I have the receiving date of the claim?
What is the general timeline to process a claim?
What are the technical protocols and standards to file a claim?

Scenario 3 - When the Claim is Forwarded to Payer from the Billing Center

Key Points to Analyze Claim forwarded date
Acknowledgment Receipt
Payer's contact number
Questions to be AskedCan I know the date on which the payer received the claim?
Could you tell me the payer's contact information?
Could you tell me the payer's contact information?

Scenario 4 - When the Claim is Paid

Key Points to Analyze Check Claim Number
Paid amount
Permissible amount
Check date
Patient's accountability
Check Write off
Cashed date
Pay to address
Questions to be AskedCan you tell me the check's number & date?
What is the allotted amount of the claim?
What is the amount paid for this DOS?
Can you tell me if there is any write-off on this claim?
How is the patient accountable for the claim?
Will you verify the pay to address?
Could you tell if the check was cashed?

Scenario 5 - Claim is Paid to the Wrong Address

Key Points to Analyze Doctor's correct pay-to-address
Electronic Fund Transfer
W9 form
Appeal via telephone to update
Canceled check copy if already cashed
If not, appeal to halt the payment and rerelease the check.
Questions to be AskedCan you verify the doctor's pay to address?
Was the claim filed electronically through EFT?
Can you update the records if the correct pay-to-address is provided?
Could you please give me the fax number to fax the correct pay-to-address?
Can I fax the updated W9 form?
Could you fax the copy of the canceled check if the check has been cashed?
Could you halt the payment for the check and re-release the check to the right address?

Scenario 6 - Claim denied for Untimely Claim Filing

Key Points to Analyze Filing Limit
Date of claim denial
Re-filing & appealing contact information
Appeal on Proof of timely filing
Fax number
Questions to be Asked Could you tell me the claim denial date?
Can I know the filing limit for the submitted claim?
Could you tell me the contact address to appeal the claim?
Could you provide me with the fax number?
Can I fax the appeal to your attention?

Scenario 7 - Claim Denied for Non-covered Services

Key Points to Analyze Date of claim denial
Exclusion policies
Claim summary
Billing information for the non-covered services
Verify if the patient can be billed
EOB appeal
Questions to be Asked Could you tell me the denial date of the submitted claim?
Can you check if the patient is enrolled in the program for billing services?
Could you state the services which are not covered under the current insurance plan?
Can I bill the patient for the current claim?
Would you provide me with a copy of this faxed or mailed EOB to me?

Scenario 8 - Claim denied for EOB from the Primary Insurance

Key Points to Analyze Date of claim denial
Eligibility at the time of service
Benefits of EOB
EOB request
Fax Number
Maximum frequency for routine service
Info on primary insurance and coverage benefits
Questions to be Asked Could you provide me with the date on which the claim was denied?
Can you send me the EOB?
Can I appeal the denial with a request for reconsideration?
Can you re-process the claim if I fax or mail you the primary EOB?

Scenario 9 - Claim Denied for COB

Key Points to Analyze Date of claim denial
Payment information from the primary payer
No fault carrier
Information on other insurance
EOB request
Fax number
Questions to be Asked Could you provide me with the date on which the claim was denied?
Can you let me know if the patient has any other insurance?
Can you provide me with the copy of the EOB via mail or fax?

Scenario 10 - Claim Denied for Capitation Arrangement

Key Points to Analyze Date of claim denial
Date of capitation contract arrangement
EOB request
Questions to be Asked Could you provide me with the date on which the claim was denied?
Can you provide me with the date on which the capitation was arranged?
Would be able to fax or mail me a copy of EOB?

Scenario 11 - Claim Denied for Authorization Number

Key Points to Analyze Date of claim denial
EOB request
Member ID
Claim limit
Software authorization requirement in the DOS
File authorization requirement in the DOS
Fax number
Questions to be Asked Would be able to provide me with the date on which the claim was denied?
Can you let me know the authorization number for DOS if any?
If I have an authorization number in the system, would you be able to re-process the claim?
If I fax you the authorization number, can you re-process the claim?
Can you send me the copy of the EOB via mail or fax?

Scenario 12 - Claim denied for PCP Referral

Key Points to Analyze Date of claim denial
EOB request
Primary care physician (PCP) referral
Fax number
Questions to be Asked Would be able to provide me with the date on which the claim was denied?

If I have a PCP referral in the system, would you be able to re-process then?
If I fax you the claim with the PCP referral number, can you re-process the claim?
Can you send me the copy of the EOB via mail or fax?