AR scenarious

AR Scenarios

1. Insurance not able to identify patient

2. Claim not on file
3. Claim in process
4. Claim paid
5. Coding denial
6. Claim denied/pended for additional information
7. Claim denied as no coverage on DOS
8. Procedure denied as non covered / not payable
9. Claim denied as benefits exhausted
10. Claim processed as capitated
11. Claim processed as offset
12. Claim denied for referral / pre authorization
13. Claim processed and applied to deductibles
14. Procedure denied as mutually inclusive
15. Claim denied for untimely filing
16. Claim denied as duplicate
17. Claim denied for primary EOB
18. Claim denied for missing / invalid information
19. Claim denied as provider non-par
20. Claim denied for pre-existing condition
21. Claim paid to patient
22. Claim denied as primary has exceeded maximum allowable charges
23. Claim denied as medically not necessary
24. Voice mail
 INSURANCE NOT ABLE TO IDENTIFY PATIENT

Search with SSN ,Name and Date of Birth Available

Not Available

Check any other

Insurance details
Not available in the Clients
Available system. Get the correct ID No. of the
patient and the eligibility
Not details
Bill the patient Call Insurance to check if
Eligible patient is eligible. Yes

Eligible Get the status for Date of

Service in question.

Get Claim Mailing Address, Phone

No., Fax No., Filing Limit Appropriate actions taken
according to the status.

Mail / Fax to the Insurance

accordingly
 CLAIM NOT ON FILE

Check for other Not

Not Active Insurance Coverage with Available
Verify Patient Eligibility the Representative /
Client System.
Active Available
Get Insurance Name, Bill Patient
No Search Exceeded
Timely filing limit Address, Phone No., ID
for proof
No., other Insurance
Within
Information.
Write-off Yes
Get Claim Mailing Address
Call the available Not
Insurance to verify eligible
eligibility.
Refile the claim
Request to mail
claim with proof of Get Claim Mailing Address,
timely filing Phone No, Fax No., Filing
Limit

Bill the Claim to the

Insurance
 CLAIM IN PROCESS

Get the date on which

›› Insurance received the claim for the first time
›› Claim was sent for processing / reprocessing

If delay Get the reason for delay and

Get the processing time request for the claim to be
processed faster

claim Reference #
Follow-up date
 CLAIM PAID

If more than
Date of payment Cheque
15 days
cashed date
If more than 6 months
Allowed amount (not encashed)
Request to cancel and
Amount paid reissue another cheque
Patient’s responsibility
Any denials?

Mode of payment cheque

EFT # EFT Cheque # If Ask for bulk

bulk amount
Verify with the tax id Single chk/ bulk chk chk
to which the transfer
was made If Paid to
Wrong Mailing address where
Address the chk was sent
Claim ref # Correct
Insurance’s Verify mailing address
fault address with tax ID Claim ref #
Provider’s
Request for fault
reissue to Request procedure to
correct address update the correct
 CODING DENIAL

Get Denial Date

Verify if the missing / invalid code is a diagnosis

code, procedure code or a modifier.

Verify if the missing code / invalid code is

found in the client system

Get the mailing address and time

limit to resubmit corrected claim

Get the claim ref #

Request to resubmit the

corrected claim
CLAIM PENDED/DENIED FOR ADDITIONAL INFORMATION

Get pended / Denial Date

Verify if additional information

requested is from patient or
provider

Check what is the additional

information required

Check with the insurance rep if any letter was sent to the patient / provider Yes Date letter
requesting additional information was sent

Time limit to submit requested information

Mailing address to submit the requested information

Claim ref #
 NO COVERAGE FOR DATE OF SERVICE

Date of denial

If DOS is within Update the Insurance with

The effective date of coverage
coverage correct details and get the
If DOS is not claim reprocessed.
within coverage
Get claim ref#

Get the reprocessing time

Check in both Clients and Claim Ref. No. for
Found system and the Insurance, Not Found further follow up per
if patient has any other protocol
Insurance coverage.

Call the other Insurance and

check for eligibility status. Not Eligible
Timely filing, Mailing address, Bill Patient
ask if they are primary for the pt
Eligible

Update the Insurance information and

file the claim.
 CLAIM DENIED AS NON–COVERED
S E R V I C E / P R O C E D U R E N O T P A Y A B LE

Date of denial

Which service is not covered

Check if the service / procedure is not covered

due to patient’s policy or provider contract.

Service non covered as Service non covered as

per Patient’s policy per provider’s contract
Get claim ref #

Appropriate action
Bill the patient code is marked on
the account for
clients action.
CLAIM DENIED AS MAXIMUM BENEFITS MET

Date of Denial

Get the service for which maximum

benefits have exhausted

Verify if maximum benefits exhausted is for,

‘amount allowed or number of visits’

Verify if lifetime benefits is exhausted or

annual benefits is exhausted

Claim reference #
CAPITATED PAYMENT

Get the date claim was processed

Get the Allowed amount, Patient’s responsibility, if any.

DOS not within

Verify the contract period for capitation. contract period
Check if the DOS is after the contract period or
within the contract period

DOS within contract

period Update the Insurance with the
appropriate details and get the
Collect ( if it’s the first time ) claim reprocessed.
Bulk amount paid to the provider
Cheque #
Address where the cheque was Get the reprocessing time and
sent Claim Ref. No. for further follow
up per protocol

Collect clm reference #

 CLAIM OFFSET

Get the date claim was processed

Get the approved amount on current claim and

patient’s responsibility.

Get the details about the Account for which an

excess payment was made
›› Patient Name and ID No.
›› Account #
›› Date of Service
›› Billed amount and excess amount

Claim reference #
CLAIM DENIED FOR NO REFERRAL OR PRIOR AUTHORIZATION

Get Denial Date

Check if the insurance requires a prior authorization from

Utilization Management Department of the Insurance or
a Paper Referral from the Patient's Primary Care
Physician (PCP)

Verify for referral in the Paper referral Prior Authorization # Verify for auth # in the
client system client system
Found Found

not found not found

Get Patients PCP's Found Verify if any hospital claim

Update the Insurance and get
Name and Phone No. associated to present claim is
the claim reprocessed.
paid / check with UR dept

Not Found
Get the reprocessing time and
Claim ref #
Claim Ref. No. for further follow Claim ref #
up per protocol

Mark the account with

appropriate action code
PAYMENT APPLIED TO DEDUCTIBLE

Get the date claim was processed

Get the amount applied to deductible.

Collect
Allowed amount on the claim
patient’s responsibility

Get the total deductible for the calendar year.

Claim reference #
 CLAIM DENIED AS MUTUALLY INCLUSIVE

Get the denial date

Get the procedure which is denied

Get the procedure to which the denied service is Inclusive

( primary procedure)

Yes Verify if relevant info / modifier is found in the

client’s system to substantiate the need for
payment
No
Update the Insurance with the
appropriate details and get the Get the
claim reprocessed. Appeal address
Appeals time limit

Get the reprocessing time and

Claim Ref. No. for further follow Get the claim ref #
up per protocol

Recommend to appeal with medical records / Modifier

 C L A I M D E N I E D F O R U N T I M E LY F I L I N G

Get Denial Date

Get the date claim was received for the first time

Claim received
Update the same with the
Timely filing limit Within the Timely
Insurance and get the claim
Filing Limit
reprocessed.
Claim not received
Within Timely Filing
Limit
Get the claim Ref. No. and
Check the client’s system for proof No
reprocessing time for further follow up.
No proof (billed within timely filing limit)

Write-off Found proof

Request to appeal. Collect
Appeals time limit
Appeals mailing address

Claim ref #
 CLAIM DENIED AS DUPLICATE

If only 1 claim is found in Collect the date of denial If more than 1 claim is
client system found in client system

Get the status of the Original

If rep
Claim. If rep does not Explain uniqueness of the claim agrees to
agree to
reprocess
reprocess
Collect relevant
information for that Request for appeal with Update the Insurance
status medical records / modifier with correct details and
and collect get the claim
Appeals mailing address reprocessed.
Appeals time limit
Claim ref #

Get the reprocessing

Claim ref # time and Claim Ref.
No. for further follow
up per protocol
CLAIM DENIED FOR PRIMARY EXPLANATION OF BENEFITS

Get Denial Date

Verify in the Clients system, if the insurance is

listed as primary insurance or secondary payor for
the patient If Primary
Secondary
Insurance
Insurance

Verify who is primary payor

Not found for the patient from insurance
rep / Medical history

Get the mailing address and the Found

time frame by which EOB
needs to be submitted. Call the insurance, check with
No eligibility, timely filing limit and
Bill the patient if they are primary payor for
the patient
Submit Primary EOB and follow up
per protocol on the same. Yes
Get the mailing address / fax
# to file the claim
CLAIM DENIED FOR MISSING/INVALID INFORMATION

Get Denial Date

Verify what information is missing / invalid

Not Found Found

Check system to find correct information

Update the Insurance with the

Request for Resubmit correct information and get the
Cannot be reprocessed
and collect claim reprocessed.
Mailing address
 Time Limit

Get the reprocessing time and Claim

Claim ref # Ref. No. for further follow up per
protocol
 CLAIM DENIED AS PROVIDER IS NON–PAR

Get Denial Date

Verify the Tax ID / PIN

Provider Par Provider

Non-Par

Yes Verify if the patient has any out of

Update the Insurance and get the claim
reprocessed. network benefit as per the policy plan.

No

Collect Claim ref #

Get the reprocessing time and Claim Ref.
No. for further follow up per protocol

Bill the patient

CLAIM DENIED FOR PRE–EXISTING CONDITION

Get the date of denial

Get the details about pre-existing condition

Verify if there is any waiting period No Bill Patient

If the DOS is
Collect the duration of waiting period
within the Waiting
period

Get the effective dates of the policy Get the claim ref #

If the DOS is not

within the Waiting
period

Update the insurance with the

appropriate details and get the
claim reprocessed.

Get the reprocessing time and

Claim Ref. No. for further follow
up per protocol
CLAIM PAID TO THE PATIENT

Get the date claim was paid

Get the reason why the Claim was paid to the

patient

Collect the payment details:

Amount paid
Cheque #

Claim ref #

Bill the Patient

CLAIM DENIED AS PRIMARY HAS EXCEEDED MAX

A L L O W A B L E CH A R G E S

Get the date on which claim was denial

Verify what would be their allowable amount if they

were primary

Check if their allowable charges is more than the If Update the insurance with the
primary insurance’s payment More appropriate details and get
the claim reprocessed.

If less

Get the claim reference # and mark the account

with appropriate action code Get the reprocessing time and
Claim Ref. No. for further follow
up per protocol
CLAIM DENIED AS MEDICALLY NOT NECESSARY

Get Denial Date

Get the procedure which is denied

Verify if a modifier exists along with Yes Update the insurance with the
denied procedure code in the client appropriate details and get the
system claim reprocessed.

No
Get the mailing address and time
limit to appeal with medical Get the reprocessing time and
records Claim Ref. No. for further follow
up per protocol

Get the claim ref #

 VOICE MAIL

Reached insurance rep’s message box

Leave message with following details

Your name
Purpose of calling
Account #
Your call-back telephone #

If no information received from

the insurance ( after two days)

Follow up on the claim

If have to leave message more
than two times

Use appropriate action code and act as per

protocol from the client