Medical Billing- It is a process of preparing,submitting and following up on claims to

insurance companies in order to receive payment for the services rendered by a health care
provider

HIPAA- Health Insurance Portability and Accountability Act.

It is an act of 1996 which Sets the standard for protecting sensitive patient data. Any
company deals with protected health information (PHI) must ensure that all the required
physical, network and process security measures are in place and followed.
It is signed by the president Bill Clinton and became effective on 14th april 2003 for
providers, medical billing companies and insurance companies.

PHI- Protected Health Information:- It is any paper or electronic information that can be
used to identify name, address, SSN, phone no, or dates. It is any personal health information
stored on paper, in a computer CD, disc or transmitted over to internet

Account Receivable (AR)- It is the process, wherein the calls from the doctors office (billing
office) is being made to the insurance company to follow up on the status of any unpaid or
partially paid claims

Claim- It is a request for payment by the provider to the insurance company.

There are two type of claim forms:

1. HCFA-1500-Healthcare Financing adminstration-Claim form used for Dr. billing.

CMS: Center for Medicare and Medicaid services

2. UB-04-Uniform(Universal)billing-claim form used for Hospital billing.

Clearing House: - This is a service that transmits claims to insurance carriers.

Prior to submitting claims the clearinghouse scrubs claims and checks for errors.
This minimizes the amount of rejected claims as most errors can be easily
Corrected. Clearinghouses electronically transmit claim information that is
Compliant with the strict HIPAA standards

Medical Coding- The process of assigning codes, ICD for Disease & CPT for Treatment, it is
a universally accepted language for doctors and insurance company.

CPT: Current Procedural terminology, it contains 5 digits

ICD: International classification of Diseases It ranges from 3-7 digits

Insurance- It is a contract between insurance company and insured. A person has to pay
premium in order to purchase a policy.

Premium- The amount which is paid to purchase the insurance policy. Premium can be
monthly, quarterly and annually.

Subscriber- The person, who pays premium, can be called as member, beneficiary and
insured.

Beneficiary\Dependent- The spouse and the children of the subscriber.

TYPES OF INSURANCE:-

Medical Insurance- It includes the identification of disease, illness and provides care and
treatment to the person who falls ill or injured.

Health Insurance- It expands the definition of medical insurance and it includes routine and
regular check up.

THREE PILLARS OF RCM (Revenue Cycle Management)

Patient- The person, who falls ill or get injured, can be called as member, insured or
subscriber.

Payer- Insurance company is called Payer.

Provider- He is a doctor who renders the service on a patient, he is also called Rendering
provider (specialist)

PCP (Primary care Physician)- He is equivalent to the family doctor, he refers the patient
to the specialist in case if he needed the specialization treatment by issuing a referral no. He
is also called referring provider.

Inpatient- A patient who requires hospitalization for more than 24 hours.

Outpatient- A person who gets the treatment from the physician office less than 24 hours.

Effective date- It is the starting date of policy.

Termination date- The end date of policy

Dos (Date of service)- The date on which patient gets treatment.

Policy id no (Insurance Identification No)- The unique id given by the insurance company.

Primary Insurance- The insurance which takes the first responsibility and pays the major
part of bill.

Secondary Insurance- The balance of the primary insurance is paid by the secondary
insurance.

Tertiary Insurance- The balance of secondary insurance is paid by the tertiary insurance.

COB- Coordination of Benefits- It contains the information of primary, secondary and

tertiary insurance in order to avoid the duplication of benefits. It is the patient responsibility
to update the COB with the insurance company.

New Patient- A new patient is the person who has not received the professional service from
the health care provider or any other provider of the same specialty in the same group
practice within

Establish Patient- A estd patient is the person who has received the professional service
from the health care provider or any other provider of the same specialty in the same group
practice within last 36 months.

Apollo Group Practice

Dr A (Cardiologist) Dr B (cardiologist) Dr C (neurologist)

01/01/2001 NP 01/01/2003 EP 01/01/2003 NP
02/01/2012 NP 01/01/2008 NP

Referral- It is an approval given by the PCP so that a patient can go and meet the specialist if
he need, it is the patient responsibility to take referral from the PCP.

Pre-authorization- It is an approval given by the insurance company to the provider in case

of in-patient stay and some high cost treatment before rendering the service. It is obtain by
the doctor staff before rendering the service.

Retro- authorization- If a provider fails to take prior authorization in case of some

unavoidable circumstances like emergency then he can take authorization after rendering the
service, It is up to insurance discretion whether they issue retro-authorization or not.

Billed Amount- The amount charged by the provider for the compensation of his service.

Allowed Amount- It is the maximum payable amount for the different services and insurance
company cannot pay more than it.

Co-pay- It is the upfront payment that a patient has to pay before each and every visit.

Co-insurance- It is the specific percentage of allowed amount, if a patient has secondary

insurance it will billed to the secondary else to the patient.

Deductible- It is a fixed annual dollar amount which has to be paid by the patient to the
provider before his or her coverage starts paying for the health care cost. It is the patient
responsibility or if he has secondary then it will be billed to the secondary else to the patient.
 Out of pocket expenses- Co-pay, co-insurance, deductible and balance bill in case of out of
network provider.

Self-Pay- It means that the patient does not have insurance, he will pay himself.

Participating Provider Non-Participating Provider

• He accepts the allowed amount as the full • He accepts the billed amount as the full and
and final payment. final payment
• He is contracted with the insurance • He is not contracted with the insurance
company company
• The difference between the billed amount • The difference between the billed amount
and the allowed amount is write off or contractualand the allowed amount is patient
adjustment in case of participating providers. responsibility(Balance bill) in case of non
• Participating provider are also called In- participating providers.
network Provider • Non-Participating provider are also called
out of -network Provider

EOB (Explanation of Benefits)- It is a financial statement which is sent by the insurance

company to the provider as well as patient, it contains the detail of denial and payment.

ERA (Electronic Remittance Advice) It is a soft copy which contain the detail of denial and
payment, it is sent by the insurance to the provider and automatically stored in the system.

Contract Maximum- The maximum amount payable for certain illness and disease in a
calendar year. It can be in terms of dollar amount or visit.

Medical Necessity- The insurance company will pay only for those services which are
require to cure patient illness and disease, medical necessity can be proved by showing
medical records

Pre-existing condition-The health problem that exist before the effective date of policy.

Waiting period- It is the period in which insurance company do not pay for the pre-existing
condition

Hospice- It is health care program for the terminally ill patient for which nothing can be done
to stop the progression of disease, treatment can only be given in order to lessen the pain and
discomfort.

CLIA (clinical laboratory improvement amendment)- It is an act of 1988 which establish

the quality standard for all laboratory testing to ensure the accuracy, reliability and timeless
of the patient test result.

COBRA (consolidated omnibus budget reconciliation act)- It is an act of 1985 states that
the employer with 20 or more than 20 employee must offer the continuation of employer
sponsored plan up to 36 months in case of voluntary resignation, termination and death of a
working spouse

Fee Schedule- It contains the list of CPT codes and their respective allowed amount.

SSN- Social Security Number- It is a 9 digit no which is given by the US govt to every US
citizen. It is in the format of 123-45-6789.

NDC -National Drug Code- It is 11 digit no in the format of 5-4-2, the first five digit
identify the manufacturer of the drug and remaining digit assign by the manufacturer to
identify the specific product and packet size (dosage size)

TIN- tax identification number- It contain 9 digit, it is assigned to an entity or individual

provider for the purpose of filing taxes, also known as tax id.

PIN- Provider Identification number:- It is assigned by the insurance company so as to

identify the rendering provider.

NPI- National Provider Identification Number: - It is 10 digit number given by the state
govt, NPI is common for all insurance company.

PLACE OF SERVICE- POS- It is the place where patient gets the treatment.

11—Office , 12—Home, 21—Inpatient, 22---Out patient, 23---Emergency,

24—Ambulatory

25- Birthday Center, 26- Military Treatment Facility, 31—Skilled Nursing Facility, 32-
Nursing Facility,34—Hospice care, 41- Ambulance Land, 42- Ambulance air or water

ABN – Advance Beneficiary Notice—It is signed by the patient only in case of Medicare or
bcbs (Blue cross blue shield), if any of these services is not paid by Medicare then patient
will be responsible for those services.

AOB- Assignment of Benefits—It is signed by the patient to authorize provider so that he

can be directly paid by the insurance.

ROI—Release of Information—It is signed by the patient to authorize the provider so that

he can release the patient health information.

Filing Limit- It is the time period in which we have to file the claim to the insurance
company. Filling limit is calculated from the date of service.

Appeal Limit- It is the time period in which we have to appeal to the insurance company and
appeal limit is calculated from the date of denial.

Appeal- When insurance company does not pay for the treatment, an appeal is the objecting
that decision.
Medicare Primary Payer (MPP)
1- If as person has Medicare and self purchased plan then Medicare is Primary.
2- Patient has Medicare or Medicaid then Medicare is primary.
3- An individual has employer sponsored plan based on his\her retirement then Medicare is
primary.

Medicare Secondary Payer (MSP)

A person has employer sponsored plan (based on his working condition) and he is still
working with the company then Medicare is Secondary.

When member have workers comp plan and medicare, will bill to workers comp first and
medicare as secondary.

Birthday Rule- Birthday rule states that primary payer is determined by the parents whose
birthday fall first in the calendar year. In the event that both the parents have same birthday,
the health insurance plan that has provided coverage longer is the primary payer.

Charity Care- When medical services is provided as no cost or at reduced cost to a patient
that cannot afford to pay.

Contractual Adjustment- The amount of charges a provider or hospital agrees to write off
and not charge the patient as per the contract terms with insurance company.

Medi gap plan (Medicare Supplement Insurance) -Medigap is extra insurance that you
buy from a private insurance to pay health care costs which is not covered by original
medicare such as co-payments and deductibles and mental health care.

Offset- This is a kind of an adjustment which is made by the insurance when excess
payments and wrong payments are made. If insurance pays to a claim more than the specified
amount or pays incorrectly it asks for a refund or adjusts / offsets the payment against the
payment of another claim. This is called as Offset.

Refund: This is the process of returning back the excess money paid by the insurance /
patient on request. If payment is received in excess than the specified amount, insurance /
patient request for a refund. The process of Refund is usually done as per the client
specifications.

Adjustment: An adjustment is an amount which had been adjusted for some reason and
may be recoverable. It can be an additional payment or correction of records on a previously
processed claim. Adjustments are done based on the client instructions. One specific type of
adjustment is the write-off.

Credit Balance- The balance that's shown in the "Balance" or "Amount Due"
Column of your account statement with a minus sign after the amount (for
Example $50- ). It may also be shown in parenthesis; ($50). The provider may
Owe the patient a refund.
 Financial Responsibility - The portion of the charges that are the responsibility
Of the patient or insured.

REIMBURSEMENT METHOD

• CAPITATION METHOD-In this method the health care provider gets lum-sum
payment from the insurance company, it is in PMPM (per member per month) basis.
Participating provider are in contract . Patient can take n number of visit, whether patient goes to
the provider or not but capitation must be paid.

• FEE FOR SERVICE- Patient goes to the provider shows insurance card, gets treatment
and claim sent to the insurance company, provider gets payment.

• EPISODE OF CARE REIMBURSEMENT:-

Insurance paid a collective consolidated amount -Pre operative --$4000

-Surgery------$3000
-Post operative--$300

CLASSIFICATION OF AMERICAN HEALTH INDUSTRY

PUBLIC INSURANCE(Fedral) PRIVATE INSURANCE

(Commercial)

1- Medicare 1- Commercial
2- Medicaid 2- No-Fault.
3- CHAMPVA 3- Managed care plan
4- CHAMPUS -Tricare HMO, PPO, POS
5- Worker's Compensation

MANAGED CARE PLANS

HMO-Health Maintenance Organization:- Patient first goes to the PCP, if he unable to
cure the disease or illness then he refers the patient to the in-network provider by issuing a
referral no. patient cannot go to the out of network provider. This is least expensive plan.

PPO- Preferred Provider Organization:-In this plan patient can go with in-network
provider or out of network provider and there is no PCP required in this plan, the expenses
incurred are higher in case of out of network and smaller in case of in-network provider. This
plan is more flexible and expensive than HMO.

POS- Point of Service: - It is a combination of HMO and PPO. Like HMO, the patient first
needs to visit PCP, if he is not able to cure the patient then he refers the patient to the in-
network provider
However, like PPO, a POS plan lets patient to see an out of network provider
without a referral from the PCP. But he incurs higher out of pocket expenses.
This is the most flexible plan available amount managed care plan.

EPO- Exclusive Provider Organization:- This plan is similar to the HMO, in both the
type of plans requires policy holders to see in-network provider and do not reimburse if they
visit out of network providers. The differences are that HMO are determined by on a
capitated, or per person basis, whereas EPO providers are only paid for services provided.
The most disadvantage of this plan that it is quite restrictive. The
network of the hospital tends to be very small than in HMO. It is nearly impossible to see out
of network provider without having to pay all of the medical fees out of your pocket.

NO FAULT:- The name of no fault insurance often confuses consumers. No-fault insurance
does not mean that the drivers are never at fault in accident. Someone is always found to be
“at fault” in a car accident whether partially or fully.
No fault actually means covering all accidental related claims. If you are injured in an
accident or your vehicle is damaged, then you deal with your own insurance company when
making a claim regardless of who is at fault for causing the accident.
in provinces of no-fault insurance, the insurance company assign the percentage of fault for
each of the drivers involved in the accident. If you are involved in the accident and it is
determined that you are at fault either completely or partially, it will go on your insurance
record and you will likely have to pay a lot more for your coverage.

NF-2 – It is a form filled by patient and submitted to the insurance to give information related
to the accident.

CHAMPVA- Civilian Health and Medical Program for Veterans Administration:- It is a

program to provide health care benefits for the dependents of veterans who are permanently
disabled as a result of service connected condition.

TRICARE- Formally called CHAMPUS -Civilian Health and Medical Program for
Uniformed Services:- It covers the medical care for the uniform service personnel (army,
navy, air force, marines and coast guards) and their families.

Workers compensation-It is a healthcare program runs under the state govt, it provides
healthcare benefits to the employees when employees suffers a work related injury, illness
and death.

Medicare:- It is the health care program which runs under federal govt.

Part A (Hospital Insurance)-Most people don't pay a premium for Part A because they or a
spouse already paid for it through their payroll taxes while working. Medicare Part A
(Hospital Insurance) helps cover inpatient care in hospitals, including critical access
hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover
hospice care and some home health care. Beneficiaries must meet certain conditions to get
these benefits.

Part B (Medical Insurance)- Most people pay a monthly premium for Part B. Medicare Part B
(Medical Insurance) helps cover doctors' services and outpatient care. It also covers some
other medical services that Part A doesn't cover, such as some of the services of physical and
occupational therapists, and some home health care. Part B helps pay for these covered
services and supplies when they are medically necessray.
Medicare Advantage Plan- Sometimes called 'Part-C, or MA-Plans, are offered by private
insurance companies approved by Medicare, you will get medicare part-A and medicare part-
B coverage from medicare advantage plan and not original medicare

Medicare Part-D- Prescription Drugs Coverage

.

Eligibility Criteria of Medicare—

1- A person should be 65 years of age or above.
2- A person under 65 years of age suffering from certain disability.
3- A person of any age suffering from End Stage Renal Disease (ESRD)(Kidney Failure).
Rail Road Medicare- It is for the retire people of rail road.

Medigap Plans—It is the private insurance company and it covers the co-insurance and
deductible which is not paid by Medicare
MEDICAID

It is a health care program for the poor people whose income is below the national poverty
guidelines. It is jointly runs under federal and state govt.
Medicaid has always been the last insurance and we cannot bill to the Medicaid patient. Their
plan is monthly basis.
Medicaid Spend Down- To reduce the excess of income by showing the medical records, a
person can get Medicaid.

CODING
ICD- International Classification of Disease 10th CM (Clinical Modification) starts from
Oct 1st 2016

It identifies disease and illness of a patient , it is of 3 or 7 digit alpha-numeric codes but when
it is more than three digit there must be a decimal point after the three digit, it can be called
as DX, Diagnosis code.

EX- ICD-9-CM V76.00 converts directly to ICD-10-CM Z12.2 (Encounter for screening
for malignant neoplasm of respiratory organs)

CPT- (Current Procedural Terminology)

It identifies the treatment given to the person, it is of 5 digit numeric and alpha numeric
codes, it can be called as procedure code and line items.
For Ex- G0202, 77051

THE DIFFERENCE BETWEEN ICD-9 AND ICD-10 CODES

The ICD-9-CM codes are very different than ICD-10-CM/PCS. There are nearly 19 times as
many procedure codes in ICD-10-PCS than in ICD-9-CM. There are nearly 5 times as many
diagnosis codes in ICD-10-CM than in ICD-9-CM. ICD-10 has alphanumeric categories
instead of numeric ones.

Modifiers:- It is a two digit numeric and alpha numeric code which enhances the value of
cpt without changing the meaning of it.

Some most common modifier:

26-Professional component (This is used to read the report, like X-ray report)

TC- Technical Component (This modifier is uses when x-ray is performed in the radiology
dept)

LT- Left side of the body-

RT- Right side of the body

76- Repeat procedure by the same physician on the same day (append when claim is denied
as duplicate)

77- Repeat procedure by the different physician on the same day ( append when claim is
denied as duplicate)

25- Significantly, separately and identifiable E$M codes by the same physician on the same
day (append when claim is denied as included/bundled)

59- Distinct procedure used with Non E$M codes by the same physician on the same day
(append when claim is denied as included/bundled)

50- States bilateral procedure and is use with surgery code performed in the same session (It
reduces reimbersement percentage)

51- States multiple procedure and is use with surgery code performed in the same session (It
reduces re-imbersement percentage)

QW- When the lab code is CLIA waved off procedure code

GV- It is use when a physician is providing a service that is related to the diagnosis for which
a patient has been enrolled in the hospice

GW- Use when services are not related to the hospice condition and patient took the
treatment from other provider who is not the part of hospice.

The CR established four new HCPCS modifiers (XE, XP, XS, XU) to define the specific
subsets of 59 modifier, a modifier used to define a 'distinct procedural Service'. These
modifiers are collectively referred to as X(EPSU) modifiers. They are the subsets of 59
modifier.

63- Procedure perform on infants less than 4kg.

29- Global procedures, those procedure where one provider is responsible for both the
professional and technical component.

47- Anesthesia by surgeon.

Individual sections are then broken down further. For example:

• Codes for Evaluation and Management: 99201-99499
• Office/other outpatient services 99201-9215
• Hospital observation services 99217-99220
• Hospital inpatient services 99221-99239
Consultations 99241-99255
• Emergency department services 99281-99288
• Critical care services 99291-99292

Credentialing: Provider credentialing, the process of getting a physician or a provider

affiliated with payers, is a critical step in the revenue cycle.
The process involves the following steps:

• Verification of provider information. ...

• Updating practice's Pay-to address. ...
• Enrolling for electronic transactions. ...
• Monitoring process
The process enables patients to utilize their insurance cards to pay for medical services consumed
and enables the provider to get reimbursed for the medical services provided. Therefore, it is
important for healthcare providers to get enrolled and credentialed with maximum payers so that
patients can use their insurance plans in your practice - failing to do so will result in the patient
looking for competing providers who are enrolled with the health insurance companies they are
subscribed to.

However, the process of getting a provider credentialed with a payer involves a lot of manual
work in terms of completing the application forms, providing clarifications to questions from
payers and following up with them to close the credentialing request. Trust Access Healthcare to
get you credentialed fasters as we understand the forms required by each payer, and their policies
and procedures.
 The process involves the following steps:

Application Evaluation. Completing required documentation and identifying exceptions.

Primary Source Documentation. Verify practitioner/ facility information from physicians.

Outbound Call Center. Obtain missing documents and updating payer's database.

Follow-up with payers. Follow-up on submitted credentialing requests.

PROVIDER ENROLLMENT

• Data Entry. Capture data, label and link images to specific providers/ facilities in
payer's database.

• Maintenance of Provider Data. Update provider information as per policies and

procedures, and CAHQ profile.

• Verification of provider information. Contact payers to determine if they have the correct
provider information on file before we submit claims

• Updating practice’s Pay-to address. Validate and update the provider's pay-to address or the
billing address

• Enrolling for electronic transactions. Our team can enroll providers for four types of electronic
transactions:

• Electronic Data Interchange (EDI)

• Electronic Remittance Advice (ERA)

• Electronic Fund Transfer (EFT) and

• CSI

• Monitoring process. A group of highly skilled team members trained to perform research and
analysis on the possible processor functionality gaps.

Denials

THE MOST PROMINENT DENIALS

• CLAIM IS NOT ON FILE-It is not a denial it is just a status that insurance has not
received the claim.

• What is the mailing address (paper claim) and the payer id (electronic claim)

• What is the effective and the termination date

• What is the timely filing limit.

• Are you the primary payer of the secondary payer.

Scenario-1Before resubmitting the claim to the insurance company, check the clearing house
report, if there has been any rejection, resolve the rejection and refile the claim.
Scenario-2 If claim is not on file and filing limit is over then we have to file the claim for
formal denial.

• CLAIM IN PROCESS-Insurance received the claim but still in process (Not a

Denial)

• When did you received the claim?

• How much time will you take to process the claim?

• What is you turn around time (TAT).

• What is the claim no and call ref no

• Patient cannot be identified (CO-31)

when rep is not able to search the patient with member id.

• Can you search the patient by the name, dob and SSN no?

Scenario 1-If rep is able to search the patient by the name, dob and SSN then take the
correct member id and update the same in you system and ask the claim status.

Scenario 2-If rep is not able to search the patient then check any previous date of service if
you find any paid then call that insurance, verify the eligibility and file the claim to that
insurance.

Scenario 3- If you do not found any paid dos then send a discrepancy letter to the
patient and if patient did not respond within 30 days then action would be bill to the patient

• CLAIM DENIED AS WE ARE NOT THE PRIMARY PAYER (CO-22)

• What is the denial date and the claim no?

 • Do you have the information of the primary carrier, if yes then take (insurance name,
member id, effective and termination date, timely filing limit) and filed the claim to the primary
insurance.

• If rep did not have the information of the primary carrier, then sent a COB letter to the
patient to update the COB with the insurance company, if patient did not respond within 30 days
then action would be bill to the patient.

5- CLAIM APPLIED TOWARDS DEDUCTIBLE (PR-1)

1- what is the claim no and the processing date?
2- What is the allowed amount?
3- How much is applied towards deductible?
4- Is this in-network deductible or out of network deductible?
5- What is the calendar year deductible?
6- How much has been meet by the member so far?
Scenario 1- If member meet full deductible then ask to reprocess the claim, ask ref
no and TAT?
Scenario 2- If deductible is not meet by the member, then bill the claim to the
secondary insurance if member has, if not then action would be bill to the
patient.

6- COVERAGE TERMINATED (CO-26 prior to coverage,27-after coverage)

Policy lapse or member is not active on the dos.
1- what is the denial date and the claim no?
2- what is the effective and termination date?
Scenario-1- If your DOS falls between effective and termination date of policy then
it is an incorrect denial reason ask rep to reprocess the claim.
Scenario-2- If your DOS falls after the termination date of policy then it is a correct
denial reason, check system or website, if you find that member has
secondary insurance then file the claim to the secondary either bill to the
patient.

7- CLAIM DENIED FOR NO AUTH/NO CERT(CO-15)

1- What is the denial date and the claim no?
2- What is the appeal limit and appeal address?

Scenario-1-Check document if service did not need auth then give the reference of the
document to the rep and ask to reprocess the claim, if insurance company did not accept that
as a proof then action would be sent appeal of no auth required along with medical records.
 Scenario-2- check in your system or website if you found auth then give that auth to
the rep and ask to reprocess the claim.

Scenario-3-you do not found auth in your system or anywhere then ask the rep to transfer
the call in auth dept and ask if there has been auth issued on that dos and for that particular
cpt, if they have auth, give the auth to the claim dept rep and ask to reprocess the claim.

Scenario-4- If rep did not have auth then create a missing batch info and escalate to the
client if they have auth then they give that auth to you through missing info.

8- CLAIM DENIED FOR NO REFERRAL--

1- What is the denial date and the claim number?
2- What is the plan type?
Scenario-1- If the plan is PPO then there is no requirement of referral, ask rep to
reprocess the claim.
Scenario-2- If plan is HMO then check, if rendering and referring provider is
same then it is an incorrect denial reason, ask rep to reprocess the claim. If you find
that both rendering and referring provider are different then it is a correct denial
reason then action would be bill to the patient.

9- CLAIM PAID TO THE PROVIDER-

1- What is the claim no and processing date.
2- What is the allowed amount?
3-How much you paid?
4- Is there any patient responsibility, co-pay, deductible and co-insurance.
5-What is the mode of payment either check of EFT. (in case of EFT you only
need to ask EFT number, date and the amount whereas in check you need to ask, is
this the single check or bulk check, if bulk then what is the amount of bulk check.)
6- What is the pay to address?
7- Is this check cashed or still pending? (If check is cashed then ask the cashed
date)
Scenario1- If check is cashed asked the cashed date. If check is not cashed and
pay to address is correct then put a tracer on the check.

Scenario-2-If the payment has been made to the incorrect address then send W9
form to update the correct pay to address and ask to issue a new check.
Scenario-3- If check has been cashed to the incorrect pay to address then escalate
to client.

10- CLAIM DENIED AS DUPLICATE (CO-18):-

1- What is the denial date and the claim no?
2- What is the status of the original claim
Scenario- If it is the exact duplicate claim and the original claim is paid then we
need to adjust this claim. If the claim is not duplicate then we append the
following modifier:-
76- Repeat procedure by the same physician on the same day
77- Repeat procedure by the different physician on the same day.

11- CLAIM DENIED FOR NON-COVERED SERVICES (CO-96)

1- What is the denial date and the claim no?
2- Whether the service not covered under patient plan or provider speciality.
Scenario1- If service is not covered under patient plan then ask for the secondary
insurance, if member did not have secondary insurance then action would be bill to
the patient.
Scenario 2- If service is not covered under provider specialty then escalate to the
client or write off the claim.

12- CLAIM DENIED FOR UNTIMELY FILING (CO-29)

1- What is the denial date and the claim no?
2- When did you receive the claim.
3- What is your filing limit.
4- Appeal limit and appeal address.
Scenario 1- If claim file within the filing limit then it is an incorrect denial reason,
ask rep to reprocess the claim.
Scenario 2- If claim filed after the filing limit then it is a correct denial reason we
have to adjust the claim by taking action code pending write off.
Scenario 3- If claim file within the filing limit and insurance recd after the filing
limit then we have to appeal with the proof of timely filing i.e clearing house
report.
 Medicare Denial Codes- PR & CO
1- Deductible amount (PR-Patient Responsibility)
2- Coinsurance amount (PR)
3- Copay amount (PR)
4- The procedure code is inconsistent with the modifier used or required modifier is missing.
5- The procedure code is inconsistent with the place of service.
6- The procedure code is inconsistent with patient's age.
7- The procedure code is inconsistent with patient's gender.
8- The procedure code is inconsistent with provider specialty.
9- The diagnosis code is inconsistent with patient's age.
10- The diagnosis code is inconsistent with patient's gender.
11- The diagnosis code is inconsistent with procedure code.
12- The diagnosis code is inconsistent with provider specialty.
13- The date of death precedes date of service.
14- The date of birth follows date of service.
15- Claim adjusted because the submitted authorization is missing or invalid.
16- Claim/service lacks information which is needed for adjudication.
17- Payment adjusted because requested information was not provided or was
insufficient/invalid.
18- Duplicate claim/service.
19- Claim denied because this is a work related injury thus liability of worker's
compensation.
21- Claim denied because this is injury/illness is the liability of no-fault.
22- Payment adjusted because this care may by covered by another payer.
23- Payment adjusted due to the impact of prior payer.
24- Charges are covered under a capitation agreement/managed care plan.
26- Expenses incurred prior to coverage.
27- Expenses incurred after to coverage terminated.
29- The time limit for filing has expired.
31- Payment adjusted as patient cannot be identified as our insured.
35- Life time benefit maximum has been reached.
42- Charges exceed our fee schedule or maximum allowable amount.
46- This service is not covered.
47- This diagnosis is not covered, missing or invalid.
48- This procedure code is not covered.
49- Routine exam and related services is not covered.
50- These are non-covered services because this is not deemed a 'medically necessity' by
payer.