US Health Care and Medical Billing Industry

1. AR MANUAL
ISSUES AND ACTIONS
Claim not on file
 Claims mailing address
 Fax #
 Whose attention the claim has to be faxed
 Effective date
 Timely filing period
 Verify id and group #.
 May I have the claims mailing address?
 Could you please give me the fax # and can I go ahead and fax it your attention?
 Is patient eligible for the DOS?
 May I have the filing limit for this claim?
Claim in process
 Date of receipt of the claim
 Processing time.
 Can I have the date on which the claim was received?
 How long would that take to process this claim?
Claim forwarded to the payer from the pricing center
 Date of forwarding of claim to the payer
 Payer phone number.
 Could you please tell me the date on which the claim was forwarded to the payer?
 Can I know the phone number for the payer please?
Claim paid
 Check #
 Check date
 Paid amount
 Allowed amount
 Patient's responsibility
 Write off
 Pay to address
 Cashed date
 Could you please tell me the check # and check date?
 How much was the allowed amount for the claim
 Can you please tell me how much was paid for this DOS?
 Are there any write off on this claim?
 What would be patient’s responsibility?
 Can you verify the pay to address for me please?
 Was the check cashed?
Claim paid to wrong address
 Verify pay to address
 Telephone appeal to update
 W9 form
 Cancelled check copy if cashed
 If not, request for stop payment and reissue the check.
 Could you verify the pay to address for me please?
 Can you go ahead and update your records if I give you the correct pay to address for
the provider over phone?
 Could you please give me the fax # and can I go ahead and fax W9 form to your
attention?
 Please fax us a copy of the cancelled check if the check has already been cashed
 Could you please put a stop payment for this check and reissue the check to the
correct address?
Claim denied for untimely filing
 Date of denial
 Re-filing and appealing address

2.  Verify timely filing limit
 Fax number.
• May I have the denial date and the filing limit for this claim?
• Can I have the address where I need to appeal for this claim?
 Could you please give me the fax # and can I go ahead and fax it to your attention?
Claim denied for eligibility
 Date of denial
 Effective/ termination date of coverage
 EOB request
• May I have the denial date for this claim?
• May I have the effective / termination date of patients policy?
 Could you please fax / mail me a copy of the EOB
Claim denied for non covered services
 Date of denial
 Details of the non covered service
 Check if patient can be billed
 EOB request.
• May I have the denial date for this claim?
• Could you please tell me the services that are not covered under this plan?
• Can we go ahead and bill the patient for this claim?
 Can I get a copy of this EOB faxed / mailed to me please?
Claim denied for EOB from the primary insurance
 Date of denial
 Information on primary insurance if the rep has with their system
 Fax number
 May I have the date this claim was denied?
 Would you be able to re-process this claim if I were to fax you the Primary EOB?
Claim denied for cob
 Date of denial
 Information of the other insurance if they have on their file
 EOB request
 May I have the date this claim was denied?
 Would you be able to tell me if the patient has any other Insurance?
 Could you fax / mail me a copy of the EOB?
Claim denied for capitation
 Date of denial
 If possible date of Capitated contract
 Request for EOB
• May I have the date this claim was denied?
• May I have the date of capitated contract?
 Could you fax / mail me a copy of the EOB?
Claim denied for authorization number
 Date of denial
 Check if there is any auth in the software mentioned for the dos
 Check if they have an auth on file for any hospital claim for the same dos
 Fax number
 EOB request.
• May I have the date this claim was denied?
• Could you please tell me if you see any authorization # for the same DOS for the
hospital claim?
• I have a authorization # in the system, could you re-process the claim if I give this
number to you now?
• Would you be able to re-process this claim if I were to fax you the claim with
authorization number?
 Could you fax / mail me a copy of the EOB?
Claim denied for referral
 Date of denial
 Check if there is any referral on the software mentioned for the dos
 Check if provider is participating

3.  Fax number
 EOB request.
 May I have the date this claim was denied?
 I have a referral # in the system, could you re-process the claim if I give this number
to you now?
 Would you be able to re-process this claim if I were to fax you the claim with referral
number?
 Could you fax / mail me a copy of the EOB?
Claim denied as bundled/ incidental/ inclusive
 Date of denial
 Major procedure to which it has been bundled
 Can we appeal with medical notes
 Fax number
 EOB request.
 May I have the date this claim was denied?
 Could you please tell me to which major procedure the claim has been bundled to?
 Can I have the address where I need to appeal for this claim?
 Could you please give me the fax # and can I go ahead and fax it to your attention?
Claim denied for referring physician
 Date of denial
 Ask if provider is the PCP
 If not ask for PCP’s name and phone number
 Insurance fax number
 EOB request.
• May I have the date this claim was denied?
• Would you be able to reprocess this claim if I give you the referring physician’s name
and UPIN #?
 Can I have your fax number?
Claim denied for incorrect provider
 Date of denial
 Correct provider info
 Fax number
 EOB request.
• May I have the date this claim was denied?
• I have the correct provider # in the system, could you re-process the claim if I give
you this information?
 Can I have your fax number please?
Claim denied as primary paid maximum
 Date of denial
 Allowed amount
 Verify the primary payment details
 EOB request.
• May I have the date this claim was denied?
• May I know the allowed amount for this claim?
• Could you please tell me how much did the primary paid on this claim?
 Could you fax / mail me a copy of the EOB?
Claim denied for wrong diagnosis
 Date of denial
 Correct diagnosis code
 Fax number
 EOB request.
• May I have the date this claim was denied?
• Could you please tell me which is correct diagnosis for this procedure?
• Can I have your fax number please?
 Could you fax / mail me a copy of the EOB?
Claim denied for modifier
 Date of denial
 Correct modifier
 Ask for fax number

4.  EOB request
 May I have the date this claim was denied?
 Could you please tell me which is correct modifier for this procedure?
 Can I have your fax number please?
 Could you fax / mail me a copy of the EOB?
Claim denied for pre-existing condition
 Date of denial
 Pre-existing condition
 EOB request
 May I have the date this claim was denied?
 Could you tell me the condition that was classified as pre-existing for this patient?
 Could you fax / mail me a copy of the EOB?
Claim denied as not medically necessary
 Date of denial
 Appeal with medical notes
 Fax number
 EOB request
 May I have the date this claim was denied?
 Can I go ahead and send the appeal with medical notes?
 Can I have your fax number please?
 Could you fax / mail me a copy of the EOB?
Claim denied for untimely follow up
 Appealing address
 Verify timely follow up time
 Fax number
 May I have the date this claim was denied?
 Can I go ahead and send the appeal with proof of timely follow up?
 Could you tell me the follow up time for this claim?
 Can I have your fax number please?
Claim denied as duplicate
 Date of denial
 Primary dos to which the claim is denied as duplicate
 Appeal with medical notes
 Fax number.
• May I have the date this claim was denied?
 Can I have the details of the primary procedure to which claim is duplicated?
• Can I go ahead and send the appeal with medical notes?
• Can I have your fax number please?
Claim denied as Offset
 Date of denial, Offset dos details, Amount offset, EOB request
• May I have the date this claim was denied?
 Could you give the details of the DOS offset to?
 How much was offset to?
• Could you fax / mail me a copy of the EOB?
Claim pending for additional information
 Details of the information required
 Fax number
 Could you tell me the information required to process this claim?
 May I have your fax number please?
Claim processed towards patient's deductible
 Processing date
 Provider in or out of network
 Break up of the benefits
 EOB request.
 May I know the date on which this claims was processed?
 Is the provider out of network?
 Could you please tell me how much was processed towards the deductible?
• Could you fax / mail me a copy of the EOB?
Claim paid to patient
 Check if provider is participating
 Payment details
 EOB request.
 May I know when was the claim paid to patient?
 Can I know how much was paid to the patient?
 Is the provider participating? Could you fax / mail me a copy of the EOB?