Medical Billing Denials and Actions

 Claim Paid
1May I know the Claim received date
2May I know the claim paid date
3May I know the claim allowed amount
4May I know the paid amount
5Is there any patient responsibility(Co-pay, Deductible, Co-ins)
Check whether insurance Paid to Provider/Patient
If ProviderIf Patient
6May I know the mode of payment whether it is EFT or ChequeGo to Question # 8
CheckEFT
May I know the the check#May I know the EFT#
May I know whether it is single check or bulk check
If it is Bulk check : May I know the bulk check amount
May I know the check issued date
May I know whether the check is cashed or not( if paid date is more than 30 days from the current calling date)
May I know the check mailing addressMay I know whether it is single amount for Bulk amount
7If check mailing address is wrong then inform the rep that check mailing address is wrong and ask her to stop the payment and request them to resend check with correct mailing address
8May I know any line items  got denied( if the claim is more than one line item) if yes
9May I know the denial reason else
10Can I have the CPT code wise breakup details cal ref#
11May I know the claim#
12Can you please fax/send the Duplicate EOB (If paid date is more than 30 days but still not resolved then we can request the duplicate EOB)
13May I know the call ref#

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Claim is in process
1May I know the Claim received date
2May I know how many days it may take to process the claim
3If the received Date is more than 30 days then need to ask below questions
4May I know the reason for the dealy
5May I know the patient effective and termination date
6When shall I call back to you
7May I know the claim#
8May I know the call ref#

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Claim denied as Primary Paid Maximum
1May I know the Claim received date
2May I know the denied date
3May I know your allowed amount for the procedure code
4Check primay insurance paid amount in application, if it is less than the sec allowable then clarify with ins rep
5May I know the claim#
6May I know the call ref#
7Could you please fax/mail the duplicate EOB

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Claim denied as Patient cannot be identified as our insured
1Could you please check with Patient Name
2Could you please check with Patient DOB
3Could you please check with Policy#
4Could you please check with Patient SSN
5Could you please check with Patient telephone#
6Could you please check with Patient address
7Could you please check with Patient Subscriber( If patient is not self)
8May I know the call ref#

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Claim denied as Duplicate Claim/Service
1May I know the Claim received date
2May I know the denied date
3May I know the original claim status
4If original claim is denied go by the denied scenerio
5If it is paid go by the paid scenerio and if it is in-process then go by the in-process scenerio
6May the original and current claim#
Could you please send the copy of EOB( duplicate copy)
7May I know the call ref#

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Claim applied towards Deductible
1May I know the Claim received date
2May I know the claim was processed
3May I know the allowed amount
4May I know what is the amount applied towards the deductible
5May I know whether It is in-network or out of network deductible
6May I know the annual deductible amount for the patient(in-network/out of network)
7May I know how much deductible met so far
8May I know the claim#
9May I know the call ref#

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Coins/Copay
1May I know the Claim received date
2May I know the claim was processed
3May I know what is the amount applied towards the copay/co-ins
4May I know the claim#
5May I know the call ref#
6Could you please fax/mail the duplicate EOB

 

 

No claim on file or Claim not on file
1May I know whether Patient effective and termination date
2If eligible-active from 08/01/14If  not eligible-
3 May I know the TFL 90 daysMay I know whether member has any other insurance/policy with u
4May I know the claim mailing address 501 frank avenue 300 garden cit ny1530If yesIf No
5May I know the EPIDMay I know the insurance Name, Policy id# and Contact#
6May I know the fax# and whose attention the claim should be faxed
7May I know the call ref#

 

Eligibility for other insurance
May I know the Patient effective and termination date
If eligible-If  not eligible-
May I know the TFLMay I know whether member has any other insurance/policy with u
May I know the claim mailing addressIf yesIf No
May I know the EPIDMay I know the insurance Name, Policy id# and Contact#
May I know the fax# and whose attention the claim should be faxed
May I know the call ref#

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Claim denied as Member not eligible at the time of service
1May I know whether the Patient effective and termination date
2If eligible-If  not eligible-
3As per the policy effective and termination date this dos is eligible could you please check that and Send the claim back for reprocess.May I know whether member has any other insurance/policy with u
4If yesIf No
5May I know the insurance Name, Policy id# and Contact#
6
7May I know the claim#
8May I know the call ref#

 

Check Eligibility for other insurance

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Claim denied as Member coverage terminated or Policy Termed
1May I know whether the Patient effective and termination date
2If eligible-If  not eligible-
3As per the policy effective and termination date this dos is eligible could you please check that and Send the claim back for reprocess.May I know whether member has been renewed his policy. If yes get the effective from
4May I know whether member has any other insurance/policy with u
5If yesIf No
6May I know the insurance Name, Policy id# and Contact#
7May I know the claim#
8May I know the call ref#

 

Follow the protocol to check Eligibility for other insurance

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Claim denied for COB or Co-ordination of benefits
1May I know the Claim received date
2May I know the denied date
3May I know whether any letter sent to patient
If YesIf No
4May I know when the letter was sent to patientCould you please send a letter to patient
5Is there any response from the patient
If YesIf No
6Could you please send the claim back for reprocessCould you please send one more letter to patient( Client specific)
7May I know the claim#
8May I know the call ref#

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Claim denied as Member enrolled in HMO/MCO
1May I know the Claim received date
2May I know the claim denied date
3May I know the HMO/MCO insurance Name, id#, Contact#( if not available in the application) else
4May I know the claim#
5May I know the call ref#

 

Call  HMO/MCO insurance and Check the Eligibility of the member
May I know the Patient effective and termination date
If eligible-If  not eligible-
 May I know the TFLMay I know whether member has any other insurance/policy with you
May I know the claim mailing addressIf yesIf No
May I know the EPIDMay I know the insurance Name, Policy id# and Contact#
May I know the fax# and whose attention the claim should be faxed
May I know the call ref#

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Claim denied for Lack of information which is needed for adjudication
1May I know the Claim received date
2May I know the claim was denied
3May I know what information is required to process the claim
4May I know from whom the required information is needed whether patient/provider
5May I know whether any letter sent to patient/Provider
6If YesIf No
7May I know when the letter was sent to patient/providerCould you please send a letter to patient/Provider
8Is there any response from the patient/provider
9If YesIf No
10Could you please send the claim back for reprocessCould you please send one more letter to patient/Provider( as per Client specific)
11May I know the claim#
12May I know the call ref#

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Claim denied for Offset
1May I know when the claim was processed
2May I know the allowed amount
3May I know the amount applied towards offset
4Is there any Patient responsibility
5May I know the claim#
6May I know to which patient is applied for offset
7May I know the patient account# , DOS and CPT
8May I know the reason for applied Offset adjustment
9May I know the call ref#

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Claim denied for Capitation
1May I know when the claim was processed
2May I know the capitation period( contract effective and termination date)
3May I know the allowed amount
4Is there any Patient responsibility
5May I know whether this procedure is covered under Capitation or FFS
If FFSIf Capitation
Could you please send the claim back for reprocess
6May I know the claim#
7May I know the call ref#

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Claim denied for Maximum benefit met
1Date when the claim was received.
2Date when the claim was denied
3May I know the Maximum Benefit amount for the patient
4May I know the date when the Maximum benefit amount reached
5May I know the claim#
6May I know the Call ref#

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Claim denied for W9 form
1Date when the claim was received.
2Date when the claim was rejected/denied
3Need to check what is the address they have in their system and tax id
4Need to get the address where the W9 form has to mailed or get the fax number and to whom attention the w9 form has to be sent..
5What is the time frame to submit the requested information..
6May I know the Claim#
7May I know the Call ref#

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Claim denied as Maximum frequency reached
1Date when the claim was received.
2Date when the claim was denied
3May I know the maximum frequency for the procedure code
4May I know the date when maximum frequency reached
5May I know the claim#
6May I know the call reference#
7Could you please fax/mail the Duplicate EOB( If it is more than 30 days from the dnd date

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Claim denied for Primary EOB or Explanation of Benefits
1May I know the Claim received date
2May I know the claim denied date
3May I know the Primary insurance Name, id#, Contact#( in application if primary ins not found) else
4May I know the appeal limit and appeal address
5May I know the fax# and whose attention claim should be faxed
6May I know the claim#
7May I know the call ref#

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Claim denied for Medical Records
1Date when the claim was received.
2Date when the claim was denied
3May I know why you required Medical Records for this service
4May I know what type of Medical Records required to process the claim
5May I know the appeal limit and address
6May I know the fax# to fax the claim with MR notes and whose attention it should be
7May I know the claim#
8May I know the Call reference#

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Claim denied for Authorization
1May I know the claim received date
2May I know the claim denied date 06/16/2017
3May I know why you required authorization for this service/cpt code the provider is ouun
4May I know whether you have any authorization# on your file
5Could you please check in the hospital claim whether you have any authorization
6May I know whether this service is covered in that authorization
7May I know the effective and termination date for that authorization
If yesIf No
Could you please send the claim back for reprocss with that authorizationCan we get the retro authorization for this service
If yesIf No
Get the retro auth and ask them to send the claim back for reprocess with that auth# elsewhether we can submit claim with MR notes
May I know the time limit to get the retro authorization
8May I know the appeal limit and address
9May I know the fax# and whose attention it should be faxed
10May I know the claim#
11May I know the Call reference#

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Claim denied for Missing/invalid/Referral authorization
1May I know the claim received date
2May I know the claim denied date
3Do you have any referral # on your file/records else go for 6
4May I know that referral #
5Could you please send the claim back for reprocess for that referral#
6May I know the PCP name, Contact#
7May I know the appeal limit and appeal address
8May I know the fax# and whose attention it should be faxed
9May I know the claim#
10May I know the Call reference#
11Call PCP office and get the referral# and get the effective and termination date

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Claim has been forwarded to pricing center
1May I know the claim processed date
2May I know the Name of the repricing center
3May I know the Batch # thru which claim was sent
4Could you please fax the Batch face sheet
5May I the repricing center telephone# and  address
6May I know the claim#
7May I know the Call reference#
8Call Repricing Center and check the status of the claim

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Claim denied as Non covered Service
1May I know the Claim received date
2May I know the claim was denied
3Check in the application whether we received any patient for the previous dos if yes clarify with ins rep else next question
If YesIf No
4Provide the information to the rep and send the claim back for reprocessMay I know whether the CPT code is Non Covered or Diagnosis code is Non covered
May I know whether it is Patient plan or Provider contract
5May I know the claim#
6May I know the call ref#

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Claim denied for Timely Filing
1May I know the Claim received date
2May I know the claim denied date
3May I know the Timely Filing Limit
4Check whether the claim is filed within the Filing Limit and received insurance within the filing limit
5If YesIf No
Clarify with insurance rep why they denied the claim and send the claim back for reprocessCan we appeal with POTF
6Appeal Limit and appeal address and appeal Fax# and attention to
7May I know the claim#
8May I know the call ref#

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Claim denied as Past Appealing Limit
1May I know the appeal received date
2May I know the claim denied date
3May I know the appeal limit
4Check in the system whether the appeal was sent  within the apealing limit.
5If YesIf No
Clarify with insurance rep why they denied the claim and send the claim back for reprocessCan we appeal again
6May I know the Appeal Limit and appeal address and appeal Fax# and attention to
7May I know the claim#
8May I know the call ref#

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Claim denied as Care may be covered by another payer, per co-ordination of benefits-COB
1May I know the Claim received date
2May I know the claim denied date
3May I know whether you are acting as primary/secondary/tertiary
PrimarySecondaryTertiary
4clarify with insurance why they denied and send the claim back for reprocessMay I know the Primary insurance Name, id#, Contact#May I know the secondary insurance Name, id#, Contact#
5May I know the claim#
6May I know the call ref#

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Claim denied as Not covered by this payer or contractor
1May I know the Claim received date
2May I know the claim denied date
3May I know the  HMO insurance name, id#, contact#, mailing address.
4May I know the claim#
5May I know the call ref#

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Voice Mail
Hi my name is xxxxx, I am with provider “xxxxxxx” checking on claims/bill status for the patient ” xxxxx” for the Date of Service”xxxx” for the billed amount “$xxxx”. My Call back# is “xxx-xxx-xxxx”. Again I repeat my name is xxxxx call back# is “xxx-xxx-xxxx”. I will be expecting your call. Thank you very much have a wonderful day.

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Claim denied as Global
1May I know the Claim received date
2May I know the claim denied date
3May I know to which procedure code it is global
4May I know the date of service( which is applied global)
5May I know the global days for the procedure
If DOS<=global daysIf DOS >global days
6Can we appeal with modifierClarify with insurance rep that after the global days only the service was performed and send the claim back for reprocess
If yesIf No
7May I know the appropriate modifier for the procedure code. If rep provides then Call telephonic re-opening line update the modifier and send the claim back for reprocessCan we appeal with Medical Records
Appeal Limit and appeal address and appeal Fax# and attention to
8May I know the claim#
9May I know the call ref#

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Claim denied as Inclusive or Bundled or Mutually exclusive
1May I know the Claim received date
2May I know the claim denied date
3May I know to which procedure code it is inclusive/bundled/mutually exclusive
4May I know to which date of service
5Can we appeal with modifier
If yesIf No
6May I know the appropriate modifier for the procedure code. If rep provides then Call telephonic re-opening line update the modifier and send the claim back for reprocessCan we appeal with Medical Records
Appeal Limit and appeal address and appeal Fax# and attention to
7May I know the claim#
8May I know the call ref#

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Claim denied for Non participating provider
1May I know the Claim received date
2May I know the claim denied date
3May I know the allowed amount
4May I know whether the given tax-id is valid for the provider or not
5Check on dos whether provider is In-network or Out of Network
6May I know whether patient having an out of network benefits
7May I know the claim#
8May I know the call ref#

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Claim denied for incorrect Place of Service
1May I know the Claim received date
2May I know the claim denied date
3May I know the correct place of service for the procedure
4May I know the appeal Limit and appeal address and appeal Fax# and attention to
5May I know the claim#
6May I know the call ref#

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Claim denied as Missing or invalid or incomplete Modifier
1May I know the Claim received date
2May I know the claim denied date
3May I know to which modifier is invalid/incomplete( if modifier submitted more than one)
4May I know the appropriate modifier for the procedure
5If Rep providesIf not provides
Call telephonic re-opening line update the modifier and send the claim back for reprocess( Medicare)May I know the appeal Limit and appeal address and appeal Fax# and attention to
6May I know the claim#
7May I know the call ref#

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Claim denied as Missing or invalid or incomplete CPT code
1May I know the Claim received date
2May I know the claim denied date
3Check in application for previous DOS whether we received any payment for same CPT
4If yesIf No
Clarify with insurance and send the claim back for reprocessMay I know whether the Procedure code invalid for the Patient Age else
May I know whether the Procedure code invalid for the Patient Sex else
May I know whether the Procedure code invalid for the DOS
May I know the appeal Limit and appeal address and appeal Fax# and attention to
5May I know the claim#
6May I know the call ref#

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Claim denied as Missing or invalid or incomplete Diagnosis code
1May I know the Claim received date
2May I know the claim denied date
3Check in application for previous dos whether we received any payment for same diagnosis code
If yesIf No
4Clarify with insurance and send the claim back for reprocessMay I know whether Diagnosis invalid for the Patient Age else
May I know whether Diagnosis invalid for the Patient Sex else
May I know whether Diagnosis invalid for the DOS
May I know the appeal Limit and appeal address and appeal Fax# and attention
5May I know the claim#
6May I know the call ref#

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Claim denied as Patient enrolled in Hospice
1May I know the Claim received date
2May I know the claim denied date
3May I know the start and End date in Hospice
4If the dos is not in the Hospice period then call ins and send the claim back for reprocess and go to step 6 else
5Can we appeal with modifier
If yesIf No
6May I know the appeal Limit and appeal address and appeal Fax# and attention toMay I know the Hospice Name and address and contact#
7May I know the claim#
8May I know the call ref#
Call Hospice insurance and check the eligibility

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Missing/invalid HCFA/CMS-1500
1May I know the Claim received date
2May I know the claim denied/rejected date
3May I know what information is missing in the HCFA/CMS-1500
4May I know to which field the information is missing/invalid in CMS-1500
5If you have the required information check with insurance rep whether they can update that information,send the claim back for reprocess then go to step 7
6May I know the appeal Limit and appeal address and appeal Fax# and attention to
7May I know the claim#
8May I know the call ref#

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Fax Back Services
1Enter the Provider Tax-identification#
2Enter the Patient Policy #
3Enter the DOS
4Enter the our Fax#

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Claim denied as Not Medically Necessary
1Date when the claim was received.
2Date when the claim was denied
3Check whether the CPT is not medically necessity or Diagnosis code is not medically necessity
4Can we appeal with Medical Records
5May I know the appeal limit and address
6May I know the fax# to fax the claim with MR notes and whose attention it should be
7May I know the claim#
8May I know the Call reference#

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Checking Eligibility of Insurance
May I know whether member effective and termination date
If eligible-If  not eligible-
 May I know the TFLMay I know whether member has any other insurance/policy with u
May I know whether you are acting as primary or secondary
May I know the claim mailing addressIf yesIf No
May I know the EPIDMay I know the insurance Name, Policy id# and Contact#
May I know the fax# and whose attention the claim should be faxed
May I know the call ref#

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