Issues and Instructions for Typical AR and Denial Management Scenarios

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 Flatworld 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 File

Key Points to Analyze

•  Mail address of claim
• Fax number
• Doctor referral letter
• Whom to fax the claim?
• Enrollee eligibility status
• Member not on the list
• Date limit
• Filing period
• Verify ID and Group number

Questions to be Asked

1.      May I have the claims mailing address?

2.      Could you please give me the fax number, and should I go ahead and fax the claim?

3.      Should I check the eligibility status of the patient to verify the entitlement on the DOS

4.      May I check with the payer to check the availability of the member?

5.      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 Asked

1.      Can I have the receiving date of the claim?

2.      What is the general timeline to process a claim?

3.      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 Asked

• Can 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 Asked

• Can 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 Asked

• Can 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?

Outsource AR & Denial Management Services to Flatworld Solutions

A HIPAA compliant medical billing & coding service provider, Flatworld Solutions excels in the AR and denial management services and offer end-to-end healthcare support services to global providers and payers. You can leverage our services to accelerate the re-submission of the denied claims, reduce healthcare operational costs, and streamline your AR & denial management process. It is our purpose to help you obtain complete and prompt reimbursement from all the payers and patients and help you sail through sans any hassles.

Outsource AR receivable, AR receivable follow-up and Denial management services to FWS to save overhead costs, achieve growth, and streamline your medical billing process. Get in touch with us now to discuss your needs with our executives.