48ARSCENERIO

ABSTRACT
I have given my time to create these 48

AR scenarios. I request all your support to
our YouTube channel in order to create
more and more for you. Hope you always
with me…
MEDICAL BILLING AR Support YOUTUBE: V BILLINGS | WEB:

VBCARRER.COM
VIJAYAKUMAR MUNUSWAMY
SCENERIOS WITH END

ACTION
V BILLINGS
SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM
7/6/21
MEDICAL BILLING AR SCENERIOS WITH END ACTION
No Scenario Questions Action

1. Whether the Patient is eligible for the date of service 1.If the patient eligible then get the
2. Check the claims mailing address, whether claim sent to correct correct mailing address/payor id and
2 Claim not on file address resubmit
3. Timely filing limit to resubmit 2. If the patient is not eligible then call
4. Call reference # the patient to find active insurance
1. Check with patient’s name, date of birth, first name, last name,
SSN #
1.Call patient to find active/correct
2. If insurance rep unable to pull then the patient doesn't have
1 Patient not on file insurance details
plan with this
2. if no active insurance then bill patient
3. That patient would have different insurance
4. Call reference #
1. What is the received date of the claim
2. Check with normal claim processing time of the payer
1.If the claim received recently(below
3. If it is within 30 days 'from the day you are calling then close
30days) please be allow some more
the call with Claim # and Call reference #
3 Claim in Process time
4. If it is more than 30 days get the delay reason of claim
2.If the claim received (over 30days) ask
processing
rep to escalate to process soon
5. Claim # and
6.Call reference #
Claim processed towards deductible Less than 30 days
1.Processed Date
2. What is the Deductible amount allowed for this claim
3. Annual Deductible amount
4. Family or individual Deductible
5. How much met by the patient
6. If it is less than 30 days from the date of calling
1.Once EOB received then, check
7. Claim #
patient has a secondary payer if the
8. Call reference #
Claim processed secondary payer is available check the
4 towards eligibility of the secondary payer and
Claim processed towards deductible More than 30 days
deductible submit with this EOB
1.Processed Date
2. If no secondary payer then bill the
2. What is the Deductible amount allowed for this claim
patient with a patient statement
3. Annual Deductible amount
4. Family or individual Deductible
5. How much met by the patient
6.Ask to which address the initial EOB-was sent
7. Request for a copy of EOB to the pay to address
8. Claim#
9. Call reference #
1. Allowed Amount
2. Paid Amount
3. Patient Responsibility and the balance of providers adjustment
amount 1.Allow some time to receive the EOB
Paid claim within 30
5 4. Paid through Check or EFT and get the check or EFT # once EOB received the send to the
days
5. Single or Bulk posting team
6. To which address the 'EOB or remittance initiated to
7. Claim #
8. Call reference #
1. Allowed Amount
2. Paid Amount
3. Patient Responsibility and the balance of providers adjustment
amount
1.Once the check trace initiated wait till
4. Paid through Check or EFT and get the check or EFT #
the time given by the rep and then call
5. Single or Bulk
Paid claim more than back to find out where the check sent
6 6.Cash date?
30 days to.
7.No cash date then request check trace
2. If check sent to a different address
6. To which address the EOB or remittance initiated to
ask to reissue a new check
7. Request for a copy of paid EOB or remittance to the Pay to
Address
8. Claim #
9. Cal reference #
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7/6/21
1.If the letter was sent to the patient

has not crossed 30 days allow some
more time.2. If the letter was sent has
crossed 30 days then bill the claim to
1. What information is required from the patient2.If COB need to
Denied for the patient.3.If claim denied for COB
update the ask how many Letters was sent to the patient3. When
9 AdditionalInformation update then check patient payment
was the last letter sent to the patient4. Mailing Address to update
from the Patient history if the payment on nearby DOS
the information5. Timely filing limit6. Claim#7. Call reference#
received from any other insurance as a
primary then check the eligibility of that
insurance and bill the claim to that
insurance.
1. Claim will be denied for additional information

2. What information is required
1.If DOS lies within the waiting period
3. If the additional information is pre-existing Information
then bill the claim to the patient.
4:Then ask From whom the information is required
Claim denied for Pre- 2. If DOS not lies between the waiting
5. For both patient and provider ask how many letters were sent
8 existing period then ask the rep to reprocess
6. When was the last letter sent
information 3.Do not bill the claim to secondary or
7. Address to update the information with the timely filing limit
consecutive payer since they are not
8.Get the start and end date of waiting period
going to process the claim.
9. Claim#
10. Call reference#
1. What medical record is required
2. If the rep doesn't have a specification of the record, mention
the same in the claim 1.If medical records found in the system
3. Check in the system whether any records available or already then submit it to the payer
Claim Denied for
sent to the payer 2.If no medical records found then
7 Medical
4. If not get the mailing address where the records need to be escalate to the client to attach the
Records
sent medical records once medical records
5. Timely filing limit attached then submit it to the payer
6. Claim#
7. Call reference#
1. Denied date
2. Check in the billing summary and see whether the denied CPT
is paid 1.Check payment history, If the same
before in any date of service by the same payer CPT was already paid on another DOS
3. If it is paid cross verify with the rep that in the previous date of then verify with the rep and reprocess
Claim denied for service the 2.If no payment found previously on
10
Invalid CPT same code got paid. this CPT code then send it to the coding
4. If it is not paid, get the corrected claim mailing address with the team to find the correct CPT once the
timely coding team updated with the new CPT
filing limit code then resubmit to the payer
5. Claim#
6. Call reference#
1. Denied date
2. Check in the billing summary and see whether the denied CPT
combination modifier is paid before in any date of service by the
1.Send to coding team to review and
same payer
provide correct modifier and once
3. If it is paid cross verify with the rep that in the previous date of
response received with correct modifier
Claim Denied for service the
then send corrected claim to insurance
11 Invalid Or Missing same combination code got paid
by updating correct dx code.
Modifier Missing Modifier
2.If coding team states that modifier is
4. If it is not paid, get the corrected claim mailing address with the
correct then send an appeal to
timely
insurance.
filing limit
5. Claim #
6. Call reference #

7/6/21

1. Denied date2. Check in the billing summary and see whether provide correct dx code and once
the denied CPTcombination diagnosis code is paid before in any response received with correct dx
Claim Denied for
date of service by the samepayer3. If it is paid cross verify with details then send corrected claim to
12 Invalid Or Missing
the rep that in the previous date of service thesame combination insurance by updating correct dx
Diagnosis
code got paid4. If it is not paid, get the corrected claim mailing code.2.If coding team states that dx
address with the timelyfiling limit5. Claim #6. Call reference # code is correct then send an appeal to
insurance.
1.If rep provides correct POS then

update it and send corrected to
1. Denied Date insurance.
2. Check the service billed and the place of service 2. If rep does not provide correct POS
Claim Denied for 3. Check in the billing summary for previous date of service then assign claim to coding team to
13 Invalid Place of information review and provide correct POS.
service 4. Get the corrected claim mailing address and timely filing limit 3.When response received as coding is
5. Claim # correct then call insurance and try to
6. Call reference #. reprocess the claim if rep disagrees
then ask for appeal details and send an
appeal to insurance.
1. Billed CPT is not valid for the modifier or vice versa
2. Check in the billing summary for the same combination got
provide correct modifier and once
paid before
response received with correct modifier
Claim Denied for CPT claims
details then send corrected claim to
14 inconsistent with 3. If yes check with the rep on the same
insurance by updating correct modifier.
Modifier 4. If no ask for corrected claim mailing address and timely filing
2.If coding team states that modifier is
limit
5. Claim #
insurance.
6. Call reference #
1. Billed CPT is not valid with Diagnosis or vice versa
provide correct dx code and once
paid before
response received with correct dx
15 Inconsistent with 3. If yes check with the rep on the same
insurance by updating correct dx code.
Diagnosis. 4. If no ask for corrected claim mailing address and timely filing
2.If coding team states that cpt & dx
limit
code combination is correct then send
5. Claim #
an appeal to insurance.
6. Call reference
1. Billed CPT is not valid for the billed Place of service or vice versa
provide correct POS. Once response
received with correct POS details then
paid before
send corrected claim to insurance by
updating correct POS.
16 Inconsistent with 3. If yes check with the rep on the same
2.When response received as coding is
POS. 4. If no ask for corrected claim mailing address and timely filing
correct then call insurance and try to
limit
reprocess the claim if rep disagrees
5. Claim #
then ask for appeal details and send an
6. Call reference #
appeal to insurance.
1. Billed CPT doesn't match with the patients age 1.Send to coding team to review and
2. Check in the billing summary for the same combination got provide correct CPT. Once response
paid before received with correct CPT details then
claims send corrected claim to insurance by
Claim Denied for CPT
Claim denied for CPT updating correct CPT.
17 Inconsistent with
4. If no ask for corrected claim mailing address and timely filing 2.When response received as coding is
Patients Age.
limit correct then call insurance and try to
3. If yes check with the rep on the same reprocess the claim if rep disagrees
5. Claim# then ask for appeal details and send an
6. Call reference# appeal to insurance.

7/6/21

provide correct CPT code and once
response received with correct CPT
Claim Denied for CPT 1. Billed CPT is not valid for patient Gender2. Ask for corrected
18 Inconsistent with claim mailing address and timely filing limit3. Claim #4. Call
insurance by updating correct CPT
Patient Gender reference#
code.2.If coding team states that dx
code is correct then send an appeal to
insurance.
1. When rep, states the claim denied for non covered service
check under 1. Check billing/claims history whether
what criteria t is non covered this same cpt code was paid already, if
2. Whether under payer, patient or provider found give that DOS to rep and get
3. If it is payer guidelines, check in the billing summary whether clarification how it was paid and ask to
Claim Denied for Non
the same send the current claim for reprocessing.
19 covered service as per
CPT paid previously. 2.If no previous dos was paid on this
Payer's Guidelines
4. If yes check with the payer on the same code then send to coding team to verify
5.If no get the corrected claim mailing address with timely filing the coding
limit 3. If coding team says the coding is
6. Claim# already correct then send an appeal.
7. Call reference #
1. Check billing/claims history whether
this same cpt code was paid already, if
1. When rep states the claim denied for non covered service found give that DOS to rep and get
check under clarification how it was paid and ask to
what criteria it is non covered send the current claim for reprocessing.
2. Whether under payer, patient or provider 2.If no previous dos was paid on this
3. If it is patient benefit plan, check in the billing summary code then send to coding team to verify
whether the same the coding
CPT paid previously 3. If coding team says the coding is
Patients Benefit Plan
4. If yes check with the payer on the same already correct then send an appeal.
5. If no get the corrected claim mailing address with timely filing 4. If appeal denied then request the
limit eob through fax or mail
6. Claim # 5.This can be billed to secondary or
7. Call reference # consecutive payer.
6. If no other payer found then bill
patient.
1. Check billing/claims history whether

1. When rep states the claim denied for non covered service this same cpt code was paid already, if
check under found give that DOS to rep and get
what criteria it is non covered clarification how it was paid and ask to
2. Whether under payer, patient or provider send the current claim for reprocessing.
3. If it is as per providers contract, check in the billing summary 2.If no previous dos was paid on this
whether the code then send to coding team to verify
same CPT paid previously the coding
Providers Contract
4:If yes check with the payer on the same 3. If coding team says the coding is
5. If no get the corrected claim mailing address with timely filing already correct then send an appeal.
limit 4. If appeal denied then request the
6. Claim # eob through fax or mail
7. Call reference # 5.Once you received the EOB through
fax then send it for posting and adjust
1. When the service billed or units billed is exhausted or exceeded
as per
1.Once you received the EOB through
Days; Weeks, Months and Year (Visit)
fax then send it for posting .
Claim Denied for 2.Check under which criteria the claim was denied
2.If patient policy is active for
Maximum Benefit 4.Get how much visits is allowed?
secondary or consecutive payer on DOS
22 Exhausted 5. How much met in the allowed visits?
then bill the claim.
Days, Weeks, Months, 3. Check in the billing summary for previous claims Information
3.If no other payer active or available
Year (Visit) 4. Get appeal or corrected claim mailing address with the time
on DOS then released the claim to
limit
patient.
5. Claim #
6. Call reference

7/6/21
1.Once you received the EOB through

1. When service is denied stating this is the maximum payment fax then send it for posting .
Claim Denied for
they will payfor this service then that comes under Maximum 2.If patient policy is active for
Maximum Benefit
23 benefit exhausted as perAmount2.Get how much Dollar amount secondary or consecutive payer on DOS
Exhaustedamount
is allowed?3. How much met in the allowed Dollar amount?4. Get then bill the claim.3.If no other payer
(Dollar) Basis
the appeal address with the time limit5. Claim#6. Call reference# active or available on DOS then
released the claim to patient.
1.Send to coding team to review if the

claim can be resubmitted by updating
modifier or not.
2.If response received with correct
1. CPT is denied since this is bundled with another procedure
modifier then send corrected claim to
Claim Denied for 2 Ask to which CPT It is bundled with and mention the same in
insurance by updating correct modifier.
Bundled. notes
3..If coding team response received as
24 Experimental. Not 3. Check whether corrected claim or appeal is possible with timely
coding is correct or you identify that
separately filing limit
their is no NCCI edit exist through any
reimbursable 4. Claim#
tools then call the insurance and ask
5. Call reference #
them to reprocess the claim. if they
deny then send an appeal to insurance.
*encoder, findacode tools there you
can also check the NCCI edit
1. When the patients policy got terminated
2. Does the policy got renewed after the termination
3. Check in the billing summary and verify whether any other 1.Always check previous DOS, if
claims where payment from any other insurance
Claim Denied for paid after the policy termination date received or not. If yes, then check the
Patient is Not Eligible eligible for the date of service eligibility for that payer for DOS and
25
for the Date Of 4. If any claim paid available check with rep on the same resubmit the claim if the patient policy
Service 5. If nothing paid check whether they have any other insurance is active.
information 2..If no active insurance found then bill
of the patient patient
6. Claim #
5. Call reference #
1. CPT included with surgery procedure code
2. Check what is the surgery CPT and get the global period
3. Global period is from 10 to 90 days
1. Send to coding team to find out
4. Check the same Surgery code CPT in the billing summary
possibility to separate out the
whether it was paid or not
procedure with main surgery by adding
Claim Denied for CPT 5. If the denied code is not within the global period, then check
modifier.
26 included with surgery with rep to reprocess
2. If there is no possibility to separate
procedure code 6. If the denied code is within the global period, then the denial is
the since the DOS between the Global
correct
period range then it should be written
7. Check whether appeal or corrected claim possible
off (adjust)
8. Get the mailing address with timely filing limit
9. Claim#
10. Call reference#
1. Denied date
2. When rep states claim denied since patient is under hospice 1.The GV modifier is used when a
3. Get from which date the patient is under hospice physician is providing a service that is
4. Get Hospice Servicing contractor number (hospice name, NPI, related to the diagnosis for which a
Claim denied for
mailing address) patient has been enrolled in hospice.
27 Patient is in
5. Mention the date and check in the billing summary whether 2.The GW modifier is used when a
HOSPICE
any claims physician is providing a service that is
paid by the same payer in the same date range not related to the diagnosis for which a
6. If yes check with the rep on the same patient has been enrolled in hospice.
7. If no then get the claim #, call reference#

7/6/21
1. When verifying with the patients information, rep states

patient is notfound2. Check with name and date of birth3. Patient 1. Get the correct member id from rep
Claim Denied for will be pulled and the Member ID will be different with the and submit corrected claim with correct
28
patient ID is.Invalid payerssystem4. Get the correct member id and mention in the member id2. If rep don’t provide to you
claim notes5. Get the corrected claim mailing address and time then assign to client assistance.
limit6. Claim#7. Call reference#
1. When verifying with the patients information, rep states unable

to pull the
patient 1. Get the correct name from rep and
2. The reason is Name of the patient mismatch with the payers submit corrected claim with correct
Claim Denied for
29 system name
Invalid Patient Name
3. Get the correct Patients name and mention in the claim notes 2. If rep don’t provide to you then
4. Get the corrected claim mailing address and time limit assign to client assistance.
5. Claim
6. Call reference #
1. Legacy #, PTAN, Provider ID all terms are same
2. When the rep is asking what is the provider ID, check providers
Information TAB 1.Check NPPES website
3. If the information is not available, then the denial is correct (https://npiregistry.cms.hhs.gov/) to
Claim denied for
4. Get what is the procedure to obtain the provider ID from the find the PTAN, if PTAN is available then
30 Provider ID
payer update and submit as corrected claim
missing
5.. Update and get the corrected claim mailing address with time 2. No PTAN available then the denial is
limit correct so adjust(write-off) the claim
6. Claim
7. Call reference
1. Legacy #, PTAN, Provider ID all terms are same
2. When the rep is asking what is the provider ID, check providers
Information TAB
1.Check NPPES website
3. If the information is available, cross verify with that number
(https://npiregistry.cms.hhs.gov/) to
4.If the number is correct ask rep to send back for reprocess
Claim denied for find the correct PTAN, if PTAN is
5. If the information is not available, then the denial is correct
31 Provider ID available then update and submit as
6. Get what is the procedure to obtain the provider ID from the
Invalid corrected claim
payer
2. No PTAN available then the denial is
7.. Update and get the corrected claim mailing address with time
correct so adjust(write-off) the claim
limit
8. Claim#
9. Call reference#
1. When verifying with the patients information, rep states unable
to pull the
patient 1. Get the correct DOB from rep and
2. The reason is DOB of the patient mismatch with the payer's submit corrected claim with correct
Claim denied for
32 system name.
Invalid Patient's DOB
3. Get the correct Patient's DOB and mention in the claim notes 2. If rep don’t provide to you then
4.Get the corrected claim mailing address and time limit assign to client assistance.
5 Claim#
6. Call reference#
1.If the primary paid amount is more
1. When the secondary payer states primary paid maximum
than or equals to secondary allowed
2. Get the secondary's allowed amount
amount then write off the charge.
3. Compare it with primary paid amount
Primary Paid
33 4. If it is more than secondary's allowed amount then the denial is
Maximum 2.If the primary paid amount is less
correct
than secondary allowed amount then
5. Claim #
its secondary insurance's responsibility
6. Call reference #
to pay the remaining amount.

7/6/21
1.NDC code requires only for Drug CPT

NDC # is updated for Drug codes1. When rep states this code is code. Drug code always starts with a
denied for NDC #, check in the line item andclaim form whether letter. Example - J0256, J2425,
NDC # is available or not2. If NDC #Is not available then get the J7649.2.In CMS1500 form, NDC code is
Claim Denied for
corrected claim mailing address withtime limit to resubmit3. If available in the shaded portion of the
34 Missing orInvalid NDC
NDC # is available then verify with rep whether the # is valid or line item field 24A3.If rep has provided
number
not4. If it is valid then the claim will be taken back for reprocess5. the correct NDC code then update it
If not valid get the corrected claim mailing address along with and submit as corrected claim4. If you
time limit6. Claim#7. Call reference # do not have access to update NDC
number then assign to client assistance.
CLIA # is under for LAB CODES

1.CLIA Waived test needs to billed with
1. When claim or code denied for CLIA #check whether any
QW modifier along with CLIA number
number
2.If rep has provided the correct CLIA
updated in BOX 23 in CMS-1500 Claim Form.
number then update it and submit as
2. If the # is there verify to the rep on the same
Claim Denied for CLIA corrected claim
35 3. If it is valid then claim will be taken back for reprocess
# 3. If you do not have access to update
4. If it is not valid then get the corrected claim mailing address
CLIA number then assign to client
with time limit
assistance.
5. Ask what is the procedure to obtain CLIA #
4. CLIA certification number is billed on
6. Claim#
box 23 of CMS-1500 Claim Form.
7. Call reference#
1. When rep states provider is not linked with the group
Claim denied for
2. Check in the billing summary whether the individual provider
provider is not
got paid
enrolled
before or not
Provider is not linked Once the provider enrolled then
36 3. Ask what is the procedure to Enrol with the group
with resubmit if not then adjust
4. Get the resubmission method along with mailing address with
group
time limit
Provider is not
5. Claim#
affiliated
6. Call reference#
1. When payer states individual provider NPI is not available or
doesn't
Claim denied for The
match with what the payer have in their system
supervising or 1.Resubmit as corrected claim with
2. Ask is it possible to get the updated NPI available with the
rendering correct Rendering provider NPI.
37 payer
provider's NPI is not 2.If correct Rendering provider NPI not
3. If not get the corrected claim mailing address •
on found then assign to client assistance
4. Timely filing limit
file with the payer
5. Claim#
6. Call reference#
Claim denied for The 1. When payer states group provider NPI is not available or
billing doesn't match
provider or medical with what the payer have in their system
1. Resubmit as corrected claim with
group's ŅPI 2. Ask is it possible to get the updated NPI available with the
correct GROUP NPI
38 is either not on file payer
2.If correct GROUP NPI not found then
with the 3. If not get the corrected claim mailing address
assign to client assistance
payer or is 4. Timely filing limit
crosswalked/ linked 5. Claim #
incorrectly. 6. Call reference #
1. When rep states claim not on file and when you verify with the
Claim Submitted to address if
incorrect the address is not matching with what we have submitted then
Address the claim has
Claim Need to be been send to wrong address, Check with rep is the Member ID 1. Resubmit to the correct mailing
39
Submitted to should be the same address provided by rep
Pricing network or 2. Get the correct address and update in the notes
different 3. Timely filing limit
address 4. Claim #
5. Call reference #

7/6/21
1.Call benefits & eligibility department

1. When payer verifies with group # of the patient2. If the group #
of the payer and get the correct group#.
is available cross verify, if it is correct then the claim will betaken
Claim denied for Then Resubmit as corrected claim with
40 back for reprocess# 3. If the # is invalid or missing then get the
invalid group # correct GROUP#2.If correct GROUP#
corrected claim mailing address 4. Timely filing limit5. Claim #6.
not found then assign to client
Call reference #
assistance.
1. When rep states provider is not participating at the time of

service,
2. Check before whether the same provider was participating or
not 1.HMO and EPO plan does not cover
3. Ask rep What plan does patient has? (HMO, PPO, EPO, POS) out of network benefit, so it can be
Claim denied for
4. If patient plan is PPO or POS ask to reprocess billed to secondary or consecutive
41 provider non
5. Also check in the billing summary whether the same provider payer
participating
got paid 2.If no other payer active or available
after the date of service for which we are calling on DOS then bill patient.
6. Ask for appeal possibility and get the address with time limit
7. Claim #
8. Call reference #
1. Check what is the place of service. If place of service is
23(emergency) then ask to reprocess.
2. If place of service is inpatient then check with the payer rep
whether
1.If Auth# is not available and Retro
hospital claim is available to see if Auth # is updated in that claim
Auth# not possible then send appeal
3. If it is available then claim will be taken back for reprocess
Claim Denied for with complete medical records to show
42 4. If it is not there also if it is not for place of service inpatient
Authorization the medical necessity
then ask the
2. If payer still denies then write off the
rep whether any possible to update retro authorization
claim.
5. If yes get the procedure how to update retro auth
6. If no get the appeal address with time limit
7. Claim #
8. Call reference #
1. Referral is missing or invalid
2. Check any # or referring provider information is available in the 1. Assign to client assistance to get the
claim Referral from PCP
3. If available cross verify on the same 2.PPO & EPO plan does not require
Claim Denied for 4. Ask rep What plan does patient has? (HMO, PPO, EPO, POS) patient to visit referring physician, so
43
Referral 5. If patient plan is PPO & EPO ask to reprocess referral is not required whereas in HMO
6. If HMO & POS plan then ask who is the PCP and their phone# & POS plan, it is necessary to visit
7. Get the corrected claim mailing address with time limit referring doctor, so referral# is
8. Claim # required.
9. Call reference #
1. Claim or code denied for not medically necessary
2. Check in the billing summary whether the same set of CPT and
Dx code got paid
before
provide correct dx code and once
3. If yes cross verify on the same
response received with correct dx
4. If no check any medical records submitted initially.
Claim Denied for details then send corrected claim to
44 5. Verify with rep whether sent medical records was reviewed
Medically Necessary insurance by updating correct dx code.
6. If no medical records was sent, get the appeal address to
2.If coding team states that dx code is
update with
proof that the denied code is medically necessary
insurance.
7. Timely filing limit
8. Claim #
9. Call reference #
1. New patient code can only billed 3 years once if that particular
patient is
not visiting the same doctor or group
2. When rep states new patient code exceeded, ask when did this
provide correct CPT code and once
New Patient Code patient
45 response received with correct CPT
Exceeded visited last time to this provider or group
3. Check in the billing summary
insurance by updating correct CPT code.
.4. Get the corrected claim mailing address with timely filing limit
5. Claim #
6. Call reference #

7/6/21
1. Medical records submitted is not clear or legible, If any pages

Claim denied for 1. Send the medical records to the
missing ordoesn't match with the submitted claim2. Open and
missing address given by rep 2. If no medical
46 check the document in the attachment3. Get the mailing address
medicalrecords or is records found in attachments then
where the clear records need to be sent4. Timely filing limit5.
not clear. assign to client assistance.
Claim6.Call reference
1. Referring provider information available in our claim doesn't 1. Assign to client assistance to get the
match with Referral from PCP
Claim denied for payer system 2.PPO & EPO plan does not require
Referring provider 2. Or the Information is missing patient to visit referring physician, so
47
information Missing 3. Get the correct PCP name and contact referral is not required whereas in HMO
Or Invalid 4. Corrected claim mailing address and timely filing limit & POS plan, it is necessary to visit
5. Claim referring doctor, so referral# is
6. Call reference # required.
1.When rep provides all details of
primary insurance then you can update
that insurance as primary and make
current insurance as secondary
insurance and resubmit the claim to
1. Calling primary payer but the denial is primary EOB
primary insurance.
2. Check in the billing summary and find whether the same payer
2.If rep does not provide primary
has paid
Primary Payer Denies insurance details then checked in
any previous claim as primary
48 The claim for Primary system if there is any other insurance
3. If yes then cross verify on the same
EOB available or patient payment history
4. If no ask who is primary payer as per the record
has any other insurance as primary, if
5. Claim #
yes then check eligibility for that
6. Call reference#
insurance and resubmit the claim to
that payer if policy is active as primary
or else release the claim to patient if
policy is inactive or no other insurance
information available.

48ARSCENERIO

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ABSTRACT

I have given my time to create these 48

MEDICAL BILLING AR Support YOUTUBE: V BILLINGS | WEB:

SCENERIOS WITH END

No Scenario Questions Action

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 1

1.If the letter was sent to the patient

1. Claim will be denied for additional information

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 2

1.Send to coding team to review and

1.If rep provides correct POS then

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 3

1.Send to coding team to review and

1. Check billing/claims history whether

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 4

1.Once you received the EOB through

1.Send to coding team to review if the

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 5

1. When verifying with the patients information, rep states

1. When verifying with the patients information, rep states unable

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 6

1.NDC code requires only for Drug CPT

CLIA # is under for LAB CODES

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 7

1.Call benefits & eligibility department

1. When rep states provider is not participating at the time of

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 8

1. Medical records submitted is not clear or legible, If any pages

SUPPORT YOUTUBE: V BILLINGS | WEB: VBCARRER.COM 9

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