S.

Scenarios Check Points

No

Check for denial date and claim#

If the procedure performed is not related to DX code then send for coding review

If the procedure performed is related to DX code then reprocess, Follow up date, Ref# (if
applicable)

If need to be appealed, need to get the appeal address, appeal limit

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
PX inconsistent not worked as per the Client instruction or not checked the prior notes.
1 with the
Diagnosis code.
If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Chk if the number of digits in the code missing or irrelevant to the earlier diagnosis, Chk if
it is not the valid diagnosis code in that year.

If the denial is correct, then send for coding review.

If need to be sent for reprocess, Follow up date, Ref# (if applicable) / If need to be be
appealed, need to get the appeal address, appeal limit

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.
Invalid diagnosis
2
code
If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

S.
Scenarios Check Points
No

Chk whether the claim was actually denied as Bundled / included with another CPT /
Global

If denied as Global, chk the Global period and chk whether the DOS falls within the Global
period. If denied as Inclusive, chk for the primary CPT Code to which it is bundled. If
modifier is there.

Based on the denial sending the claim for coding/ reprocess/appeal

If need to be sent for reprocess, Follow up date, Ref# (if applicable) / If need to be be
appealed, need to get the appeal address, appeal limit

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
3 Inclusive
not worked as per the Client instruction or not checked the prior notes.

If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

When the ins determines that the service provided pertaining to the diagnosis is not
necessary in this service condition, Chked in LCD to chk if it is related to DX

If the denial is correct, then send for coding review.

If Medical reports to be sent the type of medical report required, filing limit, mailing
address / fax#

If need to be sent for reprocess, Follow up date, Ref# (if applicable) / If need to be be
appealed, need to get the appeal address, appeal limit

Not Medically If incorrect action taken based on the incorrect analysis and incorrect probing questions or
4
necessary not worked as per the Client instruction or not checked the prior notes.

If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

S.
Scenarios Check Points
No

Payment details - Paid date, Amount, Bulk chk / Single chk/EFT, Claim# Ref# ( if
applicable ) Paid to provider's payto address, follow up date, req for EOB ( based on paid
date ), Encashement details.

If paid to provider phycical address then ask them to reprocess / follow up date

If not updated in their system, then chk for sending W9 form, address / fax#, follow up
date.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Claim paid to the

5 If incorrect disposition code / denial code given.
Provider

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Chk the resources to check the provider enrollment details and work as per client update (
esclate to Credentiallin etc..)

If incorrect disposition code / denial code given.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.
Provider not
6
eligible on DOS
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Check whether the DX is work related, check the resources for identifying the details,
prior DOS ( Demographic details, Onbase, Medical reports, Provider documentation details
etc..)

Escalating to the Client or work as per the client update

If we have the details, the same has to be sent for reprocess, Follow up date, Ref# (if
WC related applicable) / If need to be be mailed / faxed, mailing address / fax#
denials ( DOI
missing, FROI not
updated,
7 Employer
information not
updated, not
S.
Scenarios Check Points
No
WC related
denials ( DOI
missing, FROI not If incorrect action taken based on the incorrect analysis and incorrect probing questions or
updated, not worked as per the Client instruction or not checked the prior notes.
7 Employer
information not
If incorrect disposition code / denial code given.
updated, not
work related
etc..)
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Verify the test claim and see what POS is getting printed, If correct POS found ask rep to
check what POS found in the claim that was received and resend the claim

If incorrect POS found try to relate whether the POS printing is valid or not ( EG: ER billed
with POS 23 ).

It found the denial to be correct / if unable to verify whether the POS is appropriate, then
forward to coding to confirm the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.
8 Invalid POS
If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Verify the test claim and see what Modifier is getting printed, If correct modifer found ask
rep to check what modifier found in the claim that was received and resend the claim

It found the denial to be correct / if unable to verify whether the appropriate mofier, if not
found or unaware then forward to coding to confirm the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

9 Invalid modifier If incorrect disposition code / denial code given.

S.
Scenarios Check Points
No
9 Invalid modifier

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Verify ( effective and termed dates, filing limit, mailing address, payor id, Ref#-if
appliacble )

Claim to be refiled ( electronically / paper / fax )

If incorrect disposition code / denial code given.

If outcome not given in the software

Claim not in
10
system
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#

Verify ( effective and termed dates, filing limit, mailing address, payor id, Ref#-if
appliacble )

Claim to be refiled ( electronically / paper / fax )

If no coverage ( need to check for the active insurance - Utlize resource available )

Claim to be refiled ( electronically / paper / fax )

No coverage on
11 If incorrect disposition code / denial code given.
DOS

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.
11
DOS

S.
Scenarios Check Points
No

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#

Chk whether the CPT / Service is not covered as per the patient's plan. If not covered,
need to bill patient / as per Client's instruction.

Need to check for other DOS whether paid by the same carrier.

Chk if any other active insurance found for the DOS using the resources and file the claim.
Else bill the patient using the appropriate code when having the EOB.

If incorrect disposition code / denial code given.

Not a covered
12 benefit as per
patient plan
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk whether the CPT / DX is not covered as per the provider's contract. Check provider's
contract ( Insructions ) and adjust off the balance / per client's instructions.

Need to check for other DOS whether paid by the same carrier.

If incorrect disposition code / denial code given.

Not a covered
benefit as per
13 If outcome not given in the software
provider's
contract
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

S.
Scenarios Check Points
No

Check for denial date and claim#, EOB

Chk whether was that the number or visits / monthly amount per year.

Chk if any other active insurance found for the DOS using the resources and file the claim.
Else bill the patient using the appropriate code when having the EOB.

If incorrect disposition code / denial code given.

Maximum Benefit
14 If outcome not given in the software
met

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk when was the last letter sent and lasted updated date and whether any response
received, and if recd, send the claim for reprocess, followup date and ref# ( if applicable )

Bill the patient with the appropriate code

If incorrect disposition code / denial code given.

COB not updated

15 If outcome not given in the software
by PT

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk if any other active insurance found for the DOS using the resources and file the claim.
Ask the rep whether they have the other insurance details. If found, chk eligibility and biil
the claim to that insurance.

Else bill the patient using the appropriate code when having the EOB.

Other insurance
16
is primary
S.
Scenarios Check Points
No

If incorrect disposition code / denial code given.

Other insurance
16 If outcome not given in the software
is primary

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk if any other active insurance found for the DOS using the resources and file the claim.
If found, chk eligibility and biil the claim to that insurance.

Else bill the patient using the appropriate code when having the EOB.

If incorrect disposition code / denial code given.

Patient not found

17 in the insurance If outcome not given in the software
files

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk what type of information is required and when was the last letter sent and lasted
updated date and whether any response received, and if recd, send the claim for
reprocess, followup date and ref# ( if applicable )

Bill the patient with the appropriate code

If incorrect disposition code / denial code given.

Additional
18 information from If outcome not given in the software
the patient

If any issues were identified for many invoices, the same has to be escalated globally to
the Client
 Additional
18 information from
the patient
S.
Scenarios Check Points
No

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk when was the last letter sent and lasted updated date and whether any response
received, and if recd, send the claim for reprocess, followup date and ref# ( if applicable )

Bill the patient with the appropriate code

If incorrect disposition code / denial code given.

Pre-existing
19 If outcome not given in the software
Condition

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Payment details - Paid date, Amount, Bulk chk / Single chk/EFT, Claim# Ref# ( if
applicable ) Paid to provider's payto address, follow up date, req for EOB ( based on paid
date ), Encashement details.

If paid to patient incorrectly then send for reprocess, followup date ref# ( if applicable )

If paid to patient correctly then bill the patient with appropriate code.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

20 Paid to patient If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

S.
Scenarios Check Points
No

Check for processed date and claim#, EOB

Verify network information with the provider details.

If the network period was terminated before DOS, need to intimate this to the provider.

Chk if the pymt mode - was that paid to pt. If paid to pt, need to bill pt.

If incorrect disposition code / denial code given.

21 Provider Non Par
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for processed date and claim#, EOB

Whether processed as in-network or out of network deductible, Annual deductible met by

the pt.

When having EOB billing secondary insurance or Bill pt.

If EOB not there need to request for EOB ( Mail / Fax ) with follow up date, ref# ( if
applicable )

If incorrect disposition code / denial code given.

Applied towards
22
Deductible
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

S.
Scenarios Check Points
No

Chk for filing limit and the claim recd date. If the claim was received within filing limit -
send for reprocess, followup date, ref#, If need to be appealed, need to get the appeal
mailing address, / fax#, appeal limit to send with proof of filing.

If incorrect disposition code / denial code given.

If outcome not given in the software

23 Past Timely Filing
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk whether claim denied for referral auth / prior auth.

If claim denied for prior auth, chk in system, resources, prior dates for auth, chk whether
the hosp bill has prio auth. If not whether possible for retro auth ( contact number ). If
auth# is there, give the same and send the claim for reprocessing / Appeal with medical
rec with appeal address, fax#, appeal limit. If not escalating the issue to Client.
If claim denied for referral auth, chk in system, resources, prior dates for auth, If found,
chk the validity period of the referral and # of visits allowed. Else get the PCP's name and
telephone#. Then call PCP / Escalate to the client based on the Client's instructions.

If incorrect disposition code / denial code given.

24 No Authorization

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Amount that was procesed through capitation. Check if the pt has copay, request to send
the capitation information. Or escalate to client based on client's instruction.

If incorrect disposition code / denial code given.

25 Capitation
S.
Scenarios Check Points
No

If outcome not given in the software

25 Capitation
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for processed date and claim#, EOB

Reason for Offset. If recoupment done in prior with reason. Get the allowed amount.

If active insurance found, need to file the claim to that insurance aftre chking the elig. If
no active coverage, billed the pt.

If incorrect disposition code / denial code given.

26 Offset If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk the orig claim paid for the same group / chk the prior dates, chk the provider details,
If the pymt was made not for the same group, send for reprocessing, follow up date,
ref#/Appeal with appeal address /fax# and appeal limit. If pymt was already made for the
same group and found to be exact duplicate, need to adjust / work per client's instruction.
Verify ( effective and termed dates, filing limit, mailing address, payor id, Ref#-if
appliacble )

Claim to be refiled ( electronically / paper / fax )

If incorrect disposition code / denial code given.

27 Duplicate

If outcome not given in the software

27 Duplicate
S.
Scenarios Check Points
No

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk what type of information is required ( W9 / Medical Records / Questionaire / AOB )

chk whether we had already sent to the insurance, if not get mailing address / fax# /
filing limit to send the same. Work per Client's instructions.

If incorrect disposition code / denial code given.

Additional
information from If outcome not given in the software
the provider ( W9
28
/ Medical Records
/ Questionaire / If any issues were identified for many invoices, the same has to be escalated globally to
AOB ) the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Claim recd date, Claim#, follow up time, Ref# ( iff applicable )

If incorrect disposition code / denial code given.

If outcome not given in the software

Claim is in If any issues were identified for many invoices, the same has to be escalated globally to
29
process the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Verify the test claim and see what NPI is getting printed, If correct NPI found ask rep to
check what NPI found in the claim that was received of correct request to reprocess,
followup date ref#. If not resend the claim, filing limit, ref#

Referring provider
NPI / Service
S.
Scenarios Check Points
No

If incorrect disposition code / denial code given.

Referring provider If outcome not given in the software

NPI / Service
30
Facility NPI
If any issues were identified for many invoices, the same has to be escalated globally to
missing
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

S.
Scenarios Check Points
No

Check for denial date and claim#

If the procedure performed not related to DX code then send for coding review

If the procedure performed is related to DX code then reprocess, Follow up date, Ref# (if
applicable)

If need to be be appealed, need to get the appeal address, appeal limit

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
PX inconsistent not worked as per the Client instruction or not checked the prior notes.
1 with th Diagnosis
code.
If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Chk if the number of digits in the code missing or irrelevant to the earlier diagnosis, Chk if
it is not the valid diagnosis code in that year.

If the denial is correct, then send for coding review.

If need to be sent for reprocess, Follow up date, Ref# (if applicable) / If need to be be
appealed, need to get the appeal address, appeal limit

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.
Invalid diagnosis
2
code
If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

S.
Scenarios Check Points
No

Chk whether the claim was actually denied as Bundled / included with another CPT /
Global

If denied as Global, chk the Global period and chk whether the DOS falls within the Global
period. If denied as Inclusive, chk for the primary CPT Code to which it is bundled. If
modifier is there.

Based on the denial sending the claim for coding/ reprocess/appeal

If need to be sent for reprocess, Follow up date, Ref# (if applicable) / If need to be be
appealed, need to get the appeal address, appeal limit

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
3 Inclusive
not worked as per the Client instruction or not checked the prior notes.

If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

When the ins determines that the service provided pertaining to the diagnosis is not
necessary in this service condition, Chked in LCD to chk if it is related to DX

If the denial is correct, then send for coding review.

If Medical reports to be sent the type of medical report required, filing limit, mailing
address / fax#

If need to be sent for reprocess, Follow up date, Ref# (if applicable) / If need to be be
appealed, need to get the appeal address, appeal limit

Not Medically If incorrect action taken based on the incorrect analysis and incorrect probing questions or
4
necessary not worked as per the Client instruction or not checked the prior notes.

If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

S.
Scenarios Check Points
No

Payment details - Paid date, Amount, Bulk chk / Single chk/EFT, Claim# Ref# ( if
applicable ) Paid to provider's payto address, follow up date, req for EOB ( based on paid
date ), Encashement details.

If paid to provider phycical address then ask them to reprocess / follow up date

If not updated in their system, then chk for sending W9 form, address / fax#, follow up
date.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Claim paid to the

5 If incorrect disposition code / denial code given.
Provider

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Chk the resources to check the provider enrollment details and work as per client update (
esclate to Credentiallin etc..)

If incorrect disposition code / denial code given.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.
Provider not
6
eligible on DOS
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Check whether the DX is work related, check the resources for identifying the details, prior
DOS ( Demographic details, Onbase, Medical reports, Provider documentation details etc..)

Escalating to the Cient or work as per the client update

If we have the details, the same has to be sent for reprocess, Follow up date, Ref# (if
WC related applicable) / If need to be be mailed / faxed, mailing address / fax#
denials ( DOI
missing, FROI not
updated,
7 Employer
information not
updated, not
S.
Scenarios Check Points
No
WC related
denials ( DOI
missing, FROI not If incorrect action taken based on the incorrect analysis and incorrect probing questions or
updated, not worked as per the Client instruction or not checked the prior notes.
7 Employer
information not
If incorrect disposition code / denial code given.
updated, not
work related
etc..)
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Verify the test claim and see what POS is getting printed, If correct POS found ask rep to
check what POS found in the claim that was received and resend the claim

If incorrect POS found try to relate whether the POS printing is valid or not ( EG: ER billed
with POS 23 ).

It found the denial to be correct / if unable to verify whether the POS is appropriate, then
forward to coding to confirm the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.
8 Invalid POS
If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Check for denial date and claim#

Verify the test claim and see what POS is getting printed, If correct modifer found ask rep
to check what modifier found in the claim that was received and resend the claim

It found the denial to be correct / if unable to verify whether the appropriate mofier, if not
found or unaware then forward to coding to confirm the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

9 Invalid modifier If incorrect disposition code / denial code given.

S.
Scenarios Check Points
No
9 Invalid modifier

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

Verify ( effective and termed dates, filing limit, mailing address, payor id, Ref#-if
appliacble )

Claim to be refiled ( electronically / paper / fax )

If incorrect disposition code / denial code given.

If outcome not given in the software

Claim not in
10
system
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#

Verify ( effective and termed dates, filing limit, mailing address, payor id, Ref#-if
appliacble )

Claim to be refiled ( electronically / paper / fax )

If no coverage ( need to check for the active insurance - Utlize resource available )

Claim to be refiled ( electronically / paper / fax )

No coverage on
11 If incorrect disposition code / denial code given.
DOS

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.
11
DOS

S.
Scenarios Check Points
No

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#

Chk whether the CPT / Service is not covered as per the patient's plan. If not covered,
need to bill patiet / as per Client's instruction.

Need to check for other DOS whether paid by the same carrier.

Chk if any other active insurance found for the DOS using the resources and file the claim.
Else bill the patient using the appropriate code when having the EOB.

If incorrect disposition code / denial code given.

Not a covered
12 benefit as per
patient plan
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk whether the CPT / DX is not covered as per the provider's contract. Check provider's
contract ( Insructions ) and adjust off the balance / per client's instructions.

Need to check for other DOS whether paid by the same carrier.

If incorrect disposition code / denial code given.

Not a covered
benefit as per
13 If outcome not given in the software
provider's
contract
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

S.
Scenarios Check Points
No

Check for denial date and claim#, EOB

Chk whether was that the number or visits / monthly amount per year.

Chk if any other active insurance found for the DOS using the resources and file the claim.
Else bill the patient using the appropriate code when having the EOB.

If incorrect disposition code / denial code given.

Maximum Benefit
14 If outcome not given in the software
met

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk when was the last letter sent and lasted updated date and whether any response
received, and if recd, send the claim for reprocess, followup date and ref# ( if applicable )

Bill the patient with the appropriate code

If incorrect disposition code / denial code given.

COB not updated

15 If outcome not given in the software
by PT

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk if any other active insurance found for the DOS using the resources and file the claim.
Ask the rep whether they have the other insurance details. If found, chk eligibility and biil
the claim to that insurance.

Else bill the patient using the appropriate code when having the EOB.

Other insurance
16
is primary
S.
Scenarios Check Points
No

If incorrect disposition code / denial code given.

Other insurance
16 If outcome not given in the software
is primary

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk if any other active insurance found for the DOS using the resources and file the claim.
If found, chk eligibility and biil the claim to that insurance.

Else bill the patient using the appropriate code when having the EOB.

If incorrect disposition code / denial code given.

Patient not found

17 in the insurance If outcome not given in the software
files

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk what type of information is required and when was the last letter sent and lasted
updated date and whether any response received, and if recd, send the claim for
reprocess, followup date and ref# ( if applicable )

Bill the patient with the appropriate code

If incorrect disposition code / denial code given.

Additional
18 information from If outcome not given in the software
the patient

If any issues were identified for many invoices, the same has to be escalated globally to
the Client
 Additional
18 information from
the patient
S.
Scenarios Check Points
No

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk when was the last letter sent and lasted updated date and whether any response
received, and if recd, send the claim for reprocess, followup date and ref# ( if applicable )

Bill the patient with the appropriate code

If incorrect disposition code / denial code given.

Pre-existing
19 If outcome not given in the software
Condition

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Payment details - Paid date, Amount, Bulk chk / Single chk/EFT, Claim# Ref# ( if
applicable ) Paid to provider's payto address, follow up date, req for EOB ( based on paid
date ), Encashement details.

If paid to patient incorrectly then send for reprocess, followup date ref# ( if applicable )

If paid to patient correctly then bill the patient with appropriate code.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

20 Paid to patient If incorrect disposition code / denial code given.

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

Note not documented

S.
Scenarios Check Points
No

Check for processed date and claim#, EOB

Verify network information with the provider details.

If the network period was terminated before DOS, need to intimate this to the provider.

Chk if the pymt mode - was that paid to pt. If paid to pt, need to bill pt.

If incorrect disposition code / denial code given.

21 Provider Non Par
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for processed date and claim#, EOB

Whether processed as in-network or out of network deductible, Annual deductible met by

the pt.

When having EOB billing secondary insurance or Bill pt.

If EOB not there need to request for EOB ( Mail / Fax ) with follow up date, ref# ( if
applicable )

If incorrect disposition code / denial code given.

Applied towards
22
Deductible
If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

S.
Scenarios Check Points
No

Chk for filing limit and the claim recd date. If the claim was received within filing limit -
send for reprocess, followup date, ref#, If need to be appealed, need to get the appeal
mailing address, / fax#, appeal limit to send with proof of filing.

If incorrect disposition code / denial code given.

If outcome not given in the software

23 Past Timely Filing
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk whether claim denied for referral auth / prior auth.

If claim denied for prior auth, chk in system, resources, prior dates for auth, chk whether
the hosp bill has prio auth. If not whether possible for retro auth ( contact number ). If
auth# is there, give the same and send the claim for reprocessing / Appeal with medical
rec with appeal address, fax#, appeal limit. If not escalating the issue to Client.
If claim denied for referral auth, chk in system, resources, prior dates for auth, If found,
chk the validity period of the referral and # of visits allowed. Else get the PCP's name and
telephone#. Then call PCP / Escalate to the client based on the Client's instructions.

If incorrect disposition code / denial code given.

24 No Authorization

If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Amount that was procesed through capitation. Check if the pt has copay, request to send
the capitation information. Or escalate to client based on client's instruction.

If incorrect disposition code / denial code given.

25 Capitation
S.
Scenarios Check Points
No

If outcome not given in the software

25 Capitation
If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for processed date and claim#, EOB

Reason for Offset. If recoupment done in prior with reason. Get the allowed amount.

If active insurance found, need to file the claim to that insurance aftre chking the elig. If
no active coverage, billed the pt.

If incorrect disposition code / denial code given.

26 Offset If outcome not given in the software

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk the orig claim paid for the same group / chk the prior dates, chk the provider details,
If the pymt was made not for the same group, send for reprocessing, follow up date,
ref#/Appeal with appeal address /fax# and appeal limit. If pymt was already made for the
same group and found to be exact duplicate, need to adjust / work per client's instruction.
Verify ( effective and termed dates, filing limit, mailing address, payor id, Ref#-if
appliacble )

Claim to be refiled ( electronically / paper / fax )

If incorrect disposition code / denial code given.

27 Duplicate

If outcome not given in the software

27 Duplicate
S.
Scenarios Check Points
No

If any issues were identified for many invoices, the same has to be escalated globally to
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Chk what type of information is required ( W9 / Medical Records / Questionaire / AOB )

chk whether we had already sent to the insurance, if not get mailing address / fax# / filing
limit to send the same. Work per Client's instructions.

If incorrect disposition code / denial code given.

Additional
information from If outcome not given in the software
the provider ( W9
28
/ Medical Records
/ Questionaire / If any issues were identified for many invoices, the same has to be escalated globally to
AOB ) the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Claim recd date, Claim#, follow up time, Ref# ( iff applicable )

If incorrect disposition code / denial code given.

If outcome not given in the software

Claim is in If any issues were identified for many invoices, the same has to be escalated globally to
29
process the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented

Check for denial date and claim#, EOB

Verify the test claim and see what NPI is getting printed, If correct NPI found ask rep to
check what NPI found in the claim that was received of correct request to reprocess,
followup date ref#. If not resend the claim, filing limit, ref#

Referring provider
NPI / Service
S.
Scenarios Check Points
No

If incorrect disposition code / denial code given.

Referring provider If outcome not given in the software

NPI / Service
30
Facility NPI
If any issues were identified for many invoices, the same has to be escalated globally to
missing
the Client

If website facility is not utilized but call placed without checking the same.

If incorrect action taken based on the incorrect analysis and incorrect probing questions or
not worked as per the Client instruction or not checked the prior notes.

Note not documented