Clinical Info Solutions AR Billing Manual

I.Basic Billing Knowledge

1) What is Medical Billing?

Medical billing refers to the process by which a health insurance claim is prepared
and submitted to a third party payor for reimbursement. The health insurance
claim is generated in a prescribed format.

2) Who Need Billing Service Firms?

1. Clinics
2. Hospitals
3. Private Practices
4. Physical therapists
5. All specialties
6. Insurance Companies
7. HMO's/PPO's/Mco's
8. Law Firms
9. Billing offices who want to outsource
10. Physician networks
11. Government agencies

The list goes on..

3) ABOUT INSURANCE

Government Health Insurance Plans & Programs

The following are government or federal health insurance programs:

Medicare

Medicare is the largest government health insurance programs in the US, covering nearly
40 million Americans.

Medicare is a Health Insurance Program for:

• People 65 years of age and older.

• Some people with disabilities under 65.
• People with End-Stages Renal Disease (permanent kidney failure requiring
dialysis or a transplant). Medicare has Two Parts:

• Part A (Hospital Insurance)

Most people do not have to pay for Part A.

• Part B (Medical Insurance)

Most people pay monthly for Part B.

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MEDICAID

Medicaid is a federally mandated, state administered medical assistance program for

persons with incomes below the national poverty line Medicaid.

WORKERS’ COMPENSATION

Workers’ compensation programs are administered by individual states, according to

their workers’ compensation laws.Thus a workers compensation health claim is a claim
arising due to a workplace Accident, injury or illness.

TRICARE (CHAMPUS & CHAMPVA)

CHAMPUS (Civilian Health and Medical Program of the Uniformed Services). A

health care program for active and retired military personnel and their qualified family
members and dependents, is now call TRICARE STANDARD.

CHAMPVA (Civilian Health and Medical Program of the Department of Veterans

Affairs) is a health care benefits program for dependents and survivors of disabled
veterans.

TRICARE offers three healthcare options or plans. Tricare Prime, Tricare Extra and
Tricare standard, each with its own coverage rules and benefits policies.

PRIVATE HEALTH INSURANCE PLANS

Private insurance plans are sponsored by private organizations. They may offer
traditional indemnity plans or managed care plans.

Commercial plans are insurance plans that offer traditional indemnity insurance. The
claim submission rules are simpler, and they pay substantially higher than managed care
and government plans, but the premium costs of these plans will be higher.

Most Private plans falls under the category of managed care plans.

Self-pay Patients:

• Patients without Insurance Coverage are ‘Self-Pay’ Patients and the charge value
of the treatment are forwarded directly to the patients to the address registered in
the system in the form of a bill containing details of treatments and the value of
treatment due from the patient.

4) Some Important Terms

• Facility: It is the place where services are furnished. i.e., in a hospital, clinic,
laboratory etc.

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• Rendering Doctor: Name of rendering doctor or the provider who performed the
services on the patient on the Date Of Service for which a charge is being created. •
Referring Doctor: The doctor who referred the patient to the rendering doctor.
Referring doctor information is very important if services require referral
information, such as in managed care, consults, lab services etc.
For diagnostic services such as Radiology (X-Rays), referring doctor is
called the ordering doctor, who orders tests.
• Place of service: It describes the nature of services provided. Such as inpatient
hospital, outpatient hospital, home, skilled nursing facility, doctor office,
psychiatric clinic, etc.
Each POS has a payer specified two-digit POS code, which must be
reported in the claims. A list of POS codes is available. Certain services
can be performed only in specified places.
• Injury Date: The date on which the first symptoms began for the current illness,
Injury. This information is used in determining benefits or exclusions for pre-
existing conditions.
• Referral Number: This is issued by the referring doctor or the PCP ( Primary
Care Physician), referring the patient to a specialist or another doctor
Managed care plans require such referrals, without which payment may be
denied for the services done by the specialist
• Prior Authorization Number: Insurance issues prior authorization number,
authorizing the services to be provided
If services require prior authorization, the charge sheet will indicate the
prior authorization #, Services may not be paid without this number in the
claim. Important data element for claim processing
• Type of Service (TOS): It refers to type of services, such as anesthesia,
consultation, diagnostic tests, radiology, surgery, psychiatric treatment, etc.
• Primary care Physician: The PCP is the primary care physician who looks after
the primary health care needs have managed care plan number.
The PCP issues referrals to other specialists. The Specialist will not be paid by
Insurance without the referral #. The PCP’s office is a repository of patient
information and PCP contact information can help processing.
• Prior authorization: Insurance issues prior authorization number, authorizing
the services to be provided
If services require prior authorization, the charge sheet will indicate the
prior authorization #.
Services may not be paid without this number in the claim.
Important data element for claim processing.
• Date (s) of Service: The date(s) on which the doctor has rendered treatment to the
Patient.
• Procedure Code: This is a five Digit alpha numeric CPT (Central Procedural
Terminology) Code that indicates the treatment rendered to the Patient. This
might also include services and supplies. E.g., 71010, G0001

• Modifiers are two-digit numeric, alphanumeric or alpha codes that enhance or

alter the description of a service.

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Modifiers are added by the coder and such addition is part of the coding
procedure
Eg. 22-Unusual procedure, RT – Right side of organ/body, 26-
Professional Component, 50 – Bilateral Procedure
• Diagnosis Code: It is a numeric or an alphanumeric representation of patient’s
illness or condition or disease for which the treatment was rendered or diagnosed
as result of the treatment.
• Capitation: Physicians are prepaid a certain amount per patient assigned to the
practice per time period. The amount is paid for a group of services regardless of
how many services are provided to these patients.

EOB analysis can

• Help reduce the number of calls we make

• Simplify the work of the AR analyst by reducing the number of problem
accounts
• Show reimbursement patterns
• Increase and update our knowledge of billing rules and guidelines
• Help in the early detection and correction of billing errors
• Identify instances of fraud or abuse

II.CALL NOTES TEMPLATES

• The green color represents Internal Status and Blue color represents Final
Status

Claim paid
Paid
Paid not Posted

Cld ---- @ ----------------- TT ---------- , for the DOS ------------ paid on ----------for $-----
------ through EFT /chk# --------------. Total amt of the chk $----------. chk and cashed on
dt.------------ / chk is still outstanding. For the CPT ------allowed $---- and Paid $------.
Verified check mailing address. Claim#----------------, Refe#------------.

Claim not on file
CNIS
Re-Filed

Cld ---- @ -------------- TT ----------, for the DOS ------------- CNIS. Patient is effective
from ------------- to ---------------. Sugg to resubmit the claims to Verified the correct
mailing address, suggested to refile to sytem address/ if different address pls mention-----
--------------------------/Claim to be faxed to Attn:-------------# --------------------- No fax#
please mention That they do not accept claims by fax. Filing Limit -----------,Processing
time---------.

Claim in process
In-Process
In-Process

Cld----@ -------------- -- TT-----------, DOS -------------- clm is currently
under process. Received clm on ------------ It would take another -----------days/weeks to
call back for status. Normal Processing time-----------.

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Claim Dnd due to Referral
Need Referral
Day Clarification

I) Cld ------ @ ------------- TT-----------,DOS --------------- clm dnd on ------
------- for want of ref from the PCP. Asked the rep to check their system for a ref but they
could not find one. Need to refile the clm with ref to the Ins addr as in our system. Incase
different address please mention -----------------------------/ Need to fax the claim to attn:--
---------- # ----------------. Incase no fax, please mention they do not accept claims by fax.

II) Cld ------ @ ------------ -TT----------,DOS ------------- clm dnd on ---------

------for want of ref. But I questioned the rep as to how did they pay the earlier claim with
ref# -------------.She said that the ref is valid only from --------------- to --------------- and
would not cover this DOS. Need to refile the clm with ref to the Ins addr as in our
system. Incase different addr please mention -----------------------------/ Need to fax the
claim to attn:------------ # ----------------. Incase no fax, please mention they donot accept
claims by fax.

III) Cld ------ @ ---------- -- TT ---------, DOS --------------- clm dnd on

---------------for want of ref. But I questioned the rep as to how did they pay the earlier
claim with ref# -------------.She said that the ref is valid from --------------- to --------------
and It would cover this DOS and she/he would send this claim for reprocessing and it
should take ------- days/weeks.

Dnd due to Lack of prior auth
Authorization
Day Clarification / Re-Filed

I) Cld ------ @ ------------- TT-----------,DOS --------------- clm dnd on ------------- for
want of auth. Asked the rep to check their system for an auth, but they
could not find one. Need to refile the clm with auth# to the Ins addr as in our system.
Incase different addr please mention -----------------------------/ Need to fax the claim to
attn:------------ # ----------------. Incase no fax, please mention they donot accept claims by
fax.

II) Cld ------ @ ------------ -TT----------,DOS --------------- clm dnd on

---------------for want of auth. But I questioned the rep as to how did they pay the earlier
clm with auth# -------------.She/he said that the, Auth is valid only from --------------- to --
------------- for ----- visits and would not cover this DOS. Need to refile the clm with
auth# to the Ins addr as in our system. Incase different addr please mention -----------------
------------/ Need to fax the claim to attn:------------ # ----------------. Incase no fax, please
mention they donot accept claims by fax.

III) Cld ------ @ ---------- -- TT ---------, DOS --------------- clm dnd on -----
----------for want of auth. But I questioned the rep as to how did they pay the earlier clm
with auth# -------------.She said that the auth is valid from ------------- to --------------- and
It would cover this DOS and she/he would send this clm for reprocessing and it would
take ------- days/week. Need to call back.

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Claim Dnd due to incorrect POS
Invalid POS
Coding Clarification

Cld ------- @ -----------TT -------------,DOS -------------- clm dnd on ---------
--- due to incorrect POS. Need to refile the clm with correct POS to the Ins addr as in our
system. Incase different addr please mention -----------------------------/ Need to fax the
claim to attn:------------ # ----------------. Incase no fax, please mention they donot accept
claims by fax.

Claim Dnd due to Coverage Termination
Pt not Active
Billed Pt / Re-Filed
Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on ---
--------- as the policy terminated on------------.(Need to call the pt. and get the current
coverage details.)

Incorrect Denial
Incorrect Denial
In-Process

Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd
in error on --------------------- (Reason )-------------------------------------. asked the rep
to send claims for reprocessing and Need to call back in ------ days/weeks. Normal
processing time ----------------.

Diagnosis inconsistent with the CPT.
Invalid DX
Coding Clarification

Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on
------------ as the diag we billed was inconsistent with the CPT ----------. Need to refile the
clm with correct diag to the Ins addr as in our system. (Incase different address please
mention -----------------------------/ Need to fax the claim to attn:------------ # --------------.
Incase no fax, please mention they donot accept claims by fax.)
Dnd due to CPT inconsistent with POS
Invalid CPT
Coding Assistance
Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on –
---------- as the CPT we billed was inconsistent with the POS. Need to refile the clm with
correct POS to the Ins addr as in our system. Incase different addr please mention ---------
--------------------/ Need to fax the claim to attn:------------ # ----------------. Incase no fax,
please mention they do not accept claims by fax.

Dnd due to Maximum Benefits Met
Max Benefits Met
Billed Pt

Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on ---
--------- as the pt. has meet the maximum benefits of $--------- for this service. requested a
copy of the EOB to our address. Need to call the pt. and Check Current coverage info.

This type of service is not covered benefits
Not Covered by Pt Plan
Billed Pt
Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on ------
------ as the pt’s policy does not cover benefits for ----------------------- services . Need to
call the pt. and check current coverage info.

Claim Dnd as a duplicate
(Original claim Reason)
(Action)

1)Cld ------- @ -----------TT -------------,DOS --------------- clm dnd as
duplicate on ------------ as they already processed the same CPT, dos and paid us on -------
------ for $--------- chk#----------------Total amt of the chk is $-------------.chk mailed to the

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correct addr/mention the address if it is wrong.---------------------------------------------------

-----------------. Pls send us the copy of the EOB.

2) Cld ------- @ -----------TT -------------,DOS -------------- clm dnd as

duplicate on ------------ as they already processed the same CPT for the same dos and paid
us on ------------- for $--------- chk#----------------Total amt of the chk is $-------------.chk
mailed to the correct address/mention the addr if it is wrong.----------------------------------
----------------------------------------------------------------------. Need to refile the clm with
medical records and supporting documents to the Ins addr as in our system. Incase
different addr please mention -----------------------------/ Need to fax the claim to attn:------
------ # ----------------. Incase no fax, please mention they donot accept claims by fax.

Claim past the filing limit.
Untimely Filing
Untimely Filing

Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on
----------------as it has past the clm filing limit. clm filing Limit is ------ days/years from
the DOS. Need to refile the clm with the proof of timely filing to the Ins addr as in our
system. (Incase different addr please mention -----------------------------/ )Need to fax the
claim to attn:------------ # ----------------.( Incase no fax, please mention they donot accept
claims by fax. )

Claim past the appealing limit. Untimely Filing
Untimely Filing

Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd
on ----------------(Reason as stated by the rep)----------------------------------------------
------------------------------ We cannot appeal this clm as it has past the appeal limit of ------
days/years from the date of denial.

Claims with the appealing limit.
Untimely Filing
Appeal

Cld ------- @ -----------TT -------------,DOS ----------------- clm dnd on
----------------(Reason as stated by the rep)------------------------------------------------------
---------------------- We can appeal this clm as it has not past the appeal limit of ------
days/years from the date of denial. Need to refile the clm with the appeal letter to the Ins
addr as in our system. Incase different addr please mention -----------------------------/
Need to fax the claim to attn:------------ # ----------------. Incase no fax, please mention
they donot accept claims by fax

Tel# landing in VM/Answering Machine Voice Mail
Voice Mail

Cld ----- @ ------------------ listed in our system could not talk to a person but reached a
VM/Answering machine. Left message for a C/B.

Payment paid to the pt.
Paid to Pt
Billed Pt

Cld ------- @ -----------TT -------------,DOS ----------------- clm was paid to
the pt. on dt------------for $--------- or pls mention as they would not give the amt paid as
the Dr. is non par with the ins. Need to f/u with the pt.

Claim has been offset
Offset
Day Clarification

Cld ------- @ -----------TT -------------,DOS ----------------- clm was

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processed for payment but the chk did not go out as this payment was made an offset for
Pt.----------------- DOS -------------- $--------- chk#------------Chk dt------------- Reason
(paid in excess, Incorrect processing etc). Pls send us a copy of the EOB.

Payment applied to ded
Deductible
Day Clarification

Cld ------- @ -----------TT -------------,DOS -----------------$ -------- applied
towards the pt’s ded. $------- met towards the ded of $------ for the year . Requested a
copy of the EOB.

Payment applied to OOP
Out of Pocket
Billed Pt

Cld ------- @ -----------TT -------------,DOS -----------------$ -------- applied
towards the pt’s oop. $------- met towards the oop of $------ for the year. Requested a
copy of the EOB.

Claim dnd for incorrect modifier
Invalid MOD
Coding Assistance

Cld ------- @ -----------TT -------------,DOS ----------------- dnd on -----------
as the modifier in HCFA was incorrect. Need to refile the clm with correct modifier to
the Ins addr as in our system. Incase different addr please mention ---------------------------
--/ Need to fax the claim to attn:------------ # ----------------. Incase no fax, please mention
they donot accept claims by fax

Clm dnd for lack of Modifier

Cld ------- @ -----------TT -------------,DOS ----------------- dnd on -----------
due to lack of modifier. Need to refile the clm with modifier to the Ins addr as in our
system. Incase different addr please mention -----------------------------/ Need to fax the
claim to attn:------------ # ----------------. Incase no fax, please mention they donot accept
claims by fax.

Dnd as the Dr. was out of network
Non Par
Billed Pt

Cld ------- @ -----------TT -------------,DOS ----------------- dnd on -----------
as Dr./grp ------------------ is listed as non par with the ins plan ------- and this policy
would not pay for out of network benefits. Need to bill the pt.

Claim dnd for need of primary EOB
Need EOB
Day Clarification
Cld ------- @ -----------TT -------------,DOS -----------------is pending as they
need the primary EOB to process the claim. Need to refile the clm along with EOB to the
Ins addr as in our system. Incase different addr please mention -----------------------------/
Need to fax the claim to attn:------------ # ----------------. Incase no fax, please mention
they donot accept claims by fax.

Need additional Information
Additional Info
Day Clarification

Cld ------- @ -----------TT -------------,DOS -----------------is pended on -----
--------as they need additional information (eg:Office notes,Medical Records etc ) They
sent us a letter on -------------- reg this . Need to refile the clm along with eg:Office Notes
Medical Records etc ) to the Ins addr as in our system. Incase different addr please
mention -----------------------------/ Need to fax the claim to attn:------------ # ----------------.

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Incase no fax, please mention they do not accept claims by fax.

Need additional Information from the pt. Additional Info
Day Clarification
Cld ------- @ -----------TT -------------,DOS -----------------is pended on -----
--------------as they need additional information from the pt.-----------------------------------
---------(details eg:preexisting etc).They sent letter to pt. on -------------- reg this. Need to
f/u with the pt. and insist him/her to send information to ins.

Could not locate the pt. Unable to Pull
Billed Pt

Cld ------- @ -----------TT -------------,said they could not locate pt. either
by ID#, Name or the SSN. Need to call the pt. for ins details.

Modifier Inconsistent with CPT code Invalid MOD
Coding Clarification

Cld ------- @ -----------TT -------------,DOS ----------------- dnd on -----------
as the modifier is inconsistent with the CPT . Need to refile the clm with correct
modifier to the Ins addr as in our system. Incase different addr please mention ------------
-----------------/ Need to fax the claim to attn:------------ # ----------------. Incase no fax,
please mention they do not accept claims by fax

Claim Dnd for pre-existing
Pre Existing
Day Clarification

Cld ------- @ -----------TT -------------, DOS --------------------clm dnd on
dt.-----------------for Pre-existing condition. The pre-existing clause is for -----------
year/months. The ins sent a Letter to the pt. on dt.--------------. Need to bill the pt.

Claim Dnd for capitation
Capitation
Capitation

Cld ------- @ -----------TT -------------,DOS ------------------processed and
paid as capitated on dt.-----------------. Name of the PCP is---------------. The capitation
contract is effective From dt.----------------.

III. More information for Call notes:

Information should be obtained

Sl.NO Denial Code Action should be taken
from the insurance or s/w
1 TFL When the super bill received Appeal if the claim submit within limit.
If super bill received after TFL then add
Intial submission date
Dr Clar.
Denial Date otherwise add Day Clarification
TFL Limit

Appeal Limit

2 Pt not Active Effective & Termination Date

Resubmit with active coverage
If other active coverage found then
information

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otherwise Bill to Pt with clear comments

3 Inclusice Denial Date
Which CPT is inclusive with which
Resubmit the claim with valid MOD or
Code
Weather the claim billed with valid
Add Coding Clarification
MOD
4 Duplicate Call & get the original status Take action based on the original status
Weather the claims is primary or
5 Primary EOB
Secondary
If only one insurance is found then Put Day Clarification to submit the
need to update COB info or claim along with EOB
DX is Check with previous / Next DOS
Which CPT is inconsistent with
6 inconsistent with weather we received payment for this
which DX
CPT combination
otherwise Add Coding Clarification
7 Not Covered By Patient plan or Provider Contract
If not covered by Patient plan then Bill to Pt with clear comments
otherwise get detail info for not
Add Coding Clarification
covered then
Capitation Agreement / Managed
8 HMO
care plan
Check eligibility and get the HMO
information
Call HMO and get the Mem ID, Resubmit the claim to HMO with
eligibility & Mailing address necessary info
Not Covered by Resubmit the claim with correct payer
9 Get the other coverage payer then
this Payer info
otherwise Bill to Pt with clear comments
10 Authorization Why they need authorization
If this Hospital claim then call
Resubmit the claim along with Auth#
Hospital and get the Auth# and
If the PCP is other provider then call
Resubmit the claim along with Auth#
PCP office and get Auth# and
If the provider is out of network then Add Dr Clarification
Check with Insurance weather the
Auth# is valid for the DOS otherwise
add Dr Clarification
If the PCP is other provider and
Bill to Pt with clear comments
claim is office visit then
Call PCP office and get the referral #
11 Need Referral Resubmit the claim along with Referral#
then
If the PCP is other provider and
Bill to Pt with clear comments
claim is office visit then

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Patient not assign the PCP panel Bill to Pt with clear comments
Check eligibility and get the Hospice
12 Hospice
period
Resubmit the claim with GV as a
If the DOS is within Hospice then
corrected Claim
Resubmit the claim with GW as a
If the DOS is not in Hospice then
corrected Claim
Qualifying
13 Check with CPT - MOD combination Add Coding Clarification
Procedure
Check the age range of the CPT and
14 CPT Conflict Age
compare with DOB
If the CPT is valid for the Age Explain and ask reprocess the claim
otherwise Add Coding Clarification
Invalid CPT or Check weather the CPT is invalid or
15 Add Coding Clarification
MOD MOD is invalid
DX is
Chek the DX description against
16 inconsistent with Add Coding Clarification
patient gender then
Pt Gender
New Patient
Can't be billed new patient code for
17 qualifications Add Coding Clarification
Established Pt
were not met
Not Deemed
Check with DX / need resubmit with
18 Medical Add Coding Clarification
medical records
Necessity

IV. Question to be Asked

NOT IN SYSTEM ( NIS )

1. Can I get correct mailing address ?
2. What is the pt's policy effective date ?
3. Is it still active?
4. What is timely filing limit?
5. Can we send the claim through fax?. if yes fax # & to whose attention ?
6. con#

CLAIM IS IN PROCESS:
1. When did you receive the claim?
2. What is your normal processing time?
3. Can I get the claim #?
4. when can I call you back?

APPLIED TO DEDUCTABLE:
1. What the amount that was applied to deductible?
2. Let me know whether this claim was processed in or out of network?
3. What is the individual deductible for the calendar year?
4. Could you please tell me, how much the patient has met till the date?
5. Could you please tell me the claim#?

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Can I get the EOB for the pt?

BENEFITS PAID TO PATIENT:

1. Could you please tell me the reason, why the chq was mailed to the patient?
2. Can you please tell me, when was the check mailed?
3. Can you please tell me the amount paid?
4. May I know the chq? #?
5. Could you please tell me, whether the chq has cleared?
6. Can you please tell me the address where the check was mailed?
7. Could you please tell me the claim#?

PATIENT NOT ELIGIBLE:

1. Could you please tell me, when did you receive the claim?
2. Could you give me the eff Dt & Termination date of the patients policy?
3. Could you please tell me, does the patient have any other policies with you?
4. Can you please tell me, is this patient covered under any other plans?
5. Could you please tell me the claim #?

CLAIM FORWARDED TO OTHER CARRIER:

1. Could you please tell me, when did you receive the claim?
2. May I know when was the claim forwarded to other carrier?
Cross verification
3. Can I have the policy #?
4. Can I have the group #?
5. Could you please tell me the mailing address of the carrier where the claim is forwarded?
6. Could you please tell me the name and the contact number of the other carrier?
7. Could you please tell me the claim#?

ADDITIONAL DOCUMENTS (or) MEDICAL NECESSITY:

1. Could you please tell me what are the additional documents required to process the claim?
2. Can you please tell me, why do you need this document?
3. May I know the procedure code for which you need the additional documents?
4. Can you please tell me the fax# / mailing adds?
5. Could you please tell me in whose attention should I send the fax?
6. Could you please tell me the, once you receive this how long will you take to process the
claim?
7. Could you please tell me the claim #?

NO AUTHORIZATION:
1. May I know if you have an authorization for the hospital bill? ( Check if hospital bill is paid )
2. If yes : Can I have the authorization # (if they give you the auth#) can you please reprocess
the claim with this Authorization #?
3. If no: May I know if the PCP (or) the hospital is responsible for obtaining the authorization #?
4. May I have the PCP (or) the hospital name and contact #?
5. Could you please tell me the claim#?

NON COVERED BENEFITS:

1. Could you please give me the CPT code that is not covered?
2. Could you please tell whether this service is not covered by your ins or pt’s plan?
3. May I know the appeal limit to resubmit the claim?
4. Can we bill the pt for the non covered services? ( generally we have to)
5. Can we bill the pt for the non covered services
6. Could you please tell me the claim#?

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PAST FILING DEADLINE:

1. What is the filing limit( commercial Ins )
2. Could you please tell me, when did you receive the claim?
3. Could you please tell me the appeal limit, (along with PTF)
4. Could you please tell me the claim#?

PENDING ACCIDENTAL DETAILS:

1. Could you please tell me, when did you send the last letter to the patient?
2. Can I verify the pt’s add to which the letter was sent?
3. Can I have the copy of the letter sent to the patient?
4. Could you please tell me the claim #?

PENDING DATA FROM PROVIDER:

1. Could you please tell me, what are the documents needed?
2. Can I verify the mailing address to where the documents need to be sent?
3. Can I Fax the required documents?
4. If yes a) can you please tell me the fax #?
b) to whose attention should I fax the documents ?
5. Could you please tell me the claim #?
6. Is there any time frame with in which we need to send you the required Information ?

PENDING FOR HOSPITAL (or) SURGE ONS BILL:

1. Could you please tell me, when did you receive the claim?
2. Can you please make sure of the date of service if (hospital/surgeon bill is needed?)
3. Could you please tell me the claim #?

PATIENT IS NOT IDENTIFIED BY INSURANCE:

1. Could you please verify with patient ID?
Could you please verify with SSN #?
Could you please verify with patients name?
Could you please verify with patients address?
Could you please verify with Patient DOB?
2. Could you please verify with prior payment?

PENDING PRIMARY EOB:

1. Could you please tell me the correct mailing address?
2. In case the primary is acting as the secondary?
Can I have the name and the phone # of the primary ins?
3. Could you please tell me the claim #?

CLAIM IS PAID
1. Can you tell me the processed date?
2. Could you please tell me the allowed amount and the paid amount?
3. Can you please tell me the chq# and date?
4. Was the chq cashed?
5. Is it a bulk chq or a single chq? sin
6. If bulk chq: what is the total amount of the chq?
7. If necessary ask: Is there any patient’s responsibility?
8. Can you please tell me to whom the chq was issued?
9. Can I have the add to where the chq was sent?
10. Could you please tell me the claim #? 914002900101
11. Can you send the EOB through fax ( provide fax # )

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V. Internal & Final Status codes

Standard Status Codes to be used

Sl.
No Internal Status Final Status
Purged
1 Duplicate Claim Adjusted
Dr Instruction
TFL Exceeded
2 Medical Records (If Provided) Re-Filed
Coding Cleared

Inclusive
Bundled
Dx Inconsistent
3 Invalid Modifier Coding Assistance
Invalid Dx
Invalid CPT
(Related to Dx & CPT Issues) Ext...

Medical Records (If not Provided)

Idenitical Denial
4 Dr Clarification
Authorization# (If not Provided)
(Must have Dr's attention / assistance) Ext…

Deductible (If EOB not Provided)

Copay (If EOB not Provided)
5 Need Eob
Co-Ins (If EOB not Provided)
(Need EOB to move to Pt Responsibility) Ext…
Claim In Process
6 Claim sent of review In Process
(Claim got paid but check not issued) Ext…
7 Claim already paid and posted in the software Paid and Posted
8 Paid but EOB not yet received Paid not Posted
Deductible (If EOB Provided)
Copay (If EOB Provided)
9 Pt Responsibility
Co-Ins (If EOB Provided)
(EOB provided to move Pt Responsibility) Ext…

Claim Faxed / Status Request Faxed

10 Faxed
Fax Requested
CNIS (Claim not in system)
11 Insuurance Chaned / Added Re-Filed
Claim Info Corrected
12 Reached Voice Mail Voice Mail

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