DENIAL PATHWAY

Claim applied towards Capitation

DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
document may not be reproduced or reviewed by any person who is not an employee of Pacific.
 Claim applied towards Capitation

Meaning:

Patient received treatment from the provider and claim billed to insurance company but rep stated that claim
applied towards the provider capitation and stated provider was already got paid for the service which was
rendered.

Steps in CareCloud:

1. To be entered by Vishal

Pre-Call Analysis –

1. Review your claim on account level to see whether other DOS are also paid under Capitation for the
same provider.
2. Check the provider’s capitation contract sheet to verify whether provider is capitated or not?

Question to be asked On Call-

1) Processing date and claim#

2) How much is the allowed amount?
3) How much has been applied towards capitation?
4) How much is the patient responsibility?
5) Could you please verify provider’s capitated effective date?.

Claim scenario 1:

If Provider is capitated with the payor

Action:-

1. Create a task to practice to adjust.

Action Description Action Taken Code Care Cloud Follow-up

Action Days

DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
document may not be reproduced or reviewed by any person who is not an employee of Pacific.
 Ask practice for Pended: Approval for
 Create a Task NA
adjustment Write off

Claim scenario 2:

If Provider is capitated with the payor and blanket authorization exists to adjust.

Action:-

1. Make an adjustment.

Action Description Action Taken Code Care Cloud Follow-up

Action Days
If a blanket authorization
exists to adjust, no task is
Write off Write off NA
needed. (No EOB
Required)

Claim scenario 3:

If provider is not under capitation contract with the payor

Action:-

1. Ask the rep to process the claim.

2. Confirm the TAT and Reference #

Action Description Action Taken Code Care Cloud Follow-up

Action Days
Payor
Marked for Follow-Up:
 Mark for Specific
Sent claim for reprocessing Payer sent claim for
follow up follow up
review
days

DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
document may not be reproduced or reviewed by any person who is not an employee of Pacific.