‘Ask doubts and get clarified: Join in V Billings family: Website: www.vbcareer.com YouTube: https://www.youtube.com/channel/UCtaFFg9hxpUn8xHarCacgeg Instagram: https://www.instagram.com/vbcareer/, Uinkedin: https://www.linkedin.com/in/vbcareer-vbillings-528386209/ Facebook: https://www.facebook,com/Vbcareer-1UU3 /99454 /S863 WhatsApp: 9080556859 Email: vijaisun11@gmail.com AR Training, JOB assistance and placement for both fresher and experienced Email: vijaisun11@gmail.com Whatsapp: 9080556859Pert g eee! Wen-vaceneeR.com ABSTRACT ‘When | was fresher, I can’t understand the concept, there is na proper material to learn myself. Now I am good in concept also ‘created this file which contains the entire AR CALLER/Medical billing ‘concept in one shop. Even fresher ‘can understand on their own without any trainer's help. Let's ‘open it and understend the concept by yourself! Vijayakumar Munusamy VBillings INSTA/FB=VBCAREER,Future of medical billing professions in Indi What is MEDICAL BILLING?. What is RCM (Revenue Cycle Management)? 1. Patent appointment/Preregistration: Eligibility and Insurance Benefits verification: Medical Codi Demo & Charge Entry:. Payment Posting: Denial Management/AR Follow-up: 2 3. 4 5. Claim Submission: ssn G 2 8. Correspondence Follow-up: 9. AAR Caller / AR follow-up (Night Shift) Calling tea 1) Doctor Calling. 2) Insurance Calling, 3) Patient Callin 3 P's in medical bi 1. Who is Pati B. Patient ©. Patient ssn: 14 D. Patient phone number: 14 Encounter process?. 15 Transcription process: a5) Medi | Coding process? . Charge sheets/Super Bills: Charge Entry process? YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,Diagnosis code iillness/sickness)? Diagnosis code volume: Diagnosis pointer (Box# 248)?.... PT CODE: Category of CPT codes: Category | CPT CODE:... 20 6 Sections of Category I CPT Code! .uesnniannnnnn eee 0) Category Il CPT CODE: Category Ill CPT CODE: LEVELS OF CPT CODES: Modifiers: Claim filing methods: Scrubber report: Paper claim submission: LHCFA/CMS 1500.. 2.UB04/CMs1450. Place of Service Codes (POS): Tyne OF Service Cades ( TOS ): In-Network Provider/Contré Pre-existing condition, Capitatio (OFFSET): Classification of Insurances: 1. Federal Insurance: ‘AMedicare insurance: Medicare Cross Over? neue B.Medicaid Insurance: Poor people. Medicaid Spend down charges: C.CHAMPUS! .nonrne YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,DEERS: D.CHAMPVA: 2.Commercial Insurance: . 3.Workers Compensation insurances, Office of Workers Compensation Programs (OWCP)?.. 4.Liability Insurance: B. Personal Injury Protection (PIP):..1ninnsnntnninvi ea No-Fault Clause/state: Collision insurance: 43 Comprehensive coverage: 43 Third Party Coverage: 43 ‘Types of Plans: 43 HMO: Health maintenance organization..... sa POS: Point-of Service... aa. PPO: Preferred Provider Organization: EPO: Exclusive Provider Organization: Orders of insurances: Deductible: nn rence Co-Pay: 46 Co-Insurance: AB The payment determination: 1 2 3. The manual review:.. 4 5. ‘The payment: Payment Posting Billed Amount: Fee-Schedule:.nmnnnn YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,Contractual Adjustment: Important short forms used in medical billing: Claim denied for missing/invalid AUTHORIZATION (BLOCK 23) . 60 Claim denied for missing/invalid REFERRAL :(BLOCK 23) a a) Claim denied for BUNDLE/INCLUSIVE/EXCLUSIVE: cn a 61 Claim denied for Timely Filing Limit exceeded (TFL): Claim denied for Primary paid more than the secondary allowed amou 62 Claim denied far Primary E08: 2 Claim denied far Medically nat Necessary: 6 Claim denied for Co-ordination of benefits (C08) update: 63 Claim denied for Pre-existing condition: 63 Claim denied for Non covered service. a Claim denied for Patient policy terminated/Patie! Claim denied for Globe: Claim denied for Maximum benefits 65 Claim denied for Duplicate: ee Claim denied for Provider is 66 Claim processed towards Deductible: MOCK-NON-COVERED SERVICE: MOCK-AUTHORIZATION DENIAL. MOCK. Diagnosis CODE(dx) IS INCONSISTENT WITH PROCEDURE CODE(cPt): nesnnneneninnine79 ‘MOCK-Co-ordination of benefits update needed/additional information requested from patient: 83 86 MOCK -Patient policy terminated | Expenses incurred after coverage terminated YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,MOCK-DUPLICATE: 89 MOCK-INCLUSIVE | GLOBAL | BUNDLED? a : — 92 MOCK-PRE-EXISTING CONDITIONS sens ote Sere 194 Mock claim PAID: . : sen 96 NOTES FORMAT: 0 oo sw wa . see Chaim is $ETTO PAV nnn sens 14 Claim Paid a4 115 Claim denied for NO AUTHORIZATION: . Claim denied for Co-ordination of benefits update/Additionalinformatfah requested from patient: 116 Claim denied for MISSING/ABSENT REFERRAL: 116 Claim denied for Patient policy terminated. 117 Claim denied for DUPLICATE: 117 Claim denied for INCLUSIVE | GLOBAL | BUNDLI Claim denied for PRE-EXISTING CONDITIONS 118 119 Claim denied for CPT code is inconsistent Diagn Future of medical billing professions in India: ‘Medical Billing, Medical Coding, AR calling, and AR analyst having a bright future in India. USA Healthcare Market increase day by day with more complicated Disease and more big Hospital and ‘Medical Organization. Currently, India is a hub for data Processing and data solution services. Right now, India gets outsourcing from the USA and there are many possibilities the UK, Australia, and Canada also will join the list shortly. Why India remains at the top in outsourcing hub? there are many reasons particularly significant YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,cost savings that companies can achieve also India has young, educated & energetic associates who provide consistently high-quality services. AAR caller, you will be responsible for making calls to insurance companies to follow-up on pending claims What is MEDICAL BILLING? Medical billing i the process for creating and submitting claims to the insurance company to receive payment for the treatment provided by the doctor to patients. What is RCM (Revenue Cycle Management)? sen ee eee eee eee eee ee medical services and ends with successful payment collection ee eae Luray Pea’ Cry oe Me 7.Denia a | Yrevaituincs Wen-vaceneeR.com INSTA/FB=VBCAREER,1. Patent appointment/Preregistration: Revenue Cycle Management (RCM) starts with the patient's appointment. A patient can get a doctor’s appoint ‘all, online, or by visiting the dactor's office/hospital. An appointment shoulda least 48 hours prior. ‘Once the Appointment is scheduled, necessary information liltspatient.demograp! insurance deteils, and reason for Visit, etc are taker Eligibility and insurance Benefits verifigatiot intment, patient eligibility and verify that the services that the patient ier details like Co-pay, Coinsurance, ined during this process. Once eligibility and front Ue Medical coders review the complete medical records and convert them into codes. On the claim form patient Diagnosis (ICD), Current Procedural YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,10 ‘Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) is used. 4, Demo & Charge Entry: ‘those data on the claim form or in the billing software. | with all the billing details, service details, provider detail details. A claim form can be filled in by hand or via using 5. Claim Submission: When the claim gets approved for payment, the insurance company sends paid EOB or ERA along with payment. The EOB is posted manually or electronically by the payment posting team. Payment will be issued through different modes of transmissions: YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,a Paper Check EFT (Electronic Fund Transfer) Virtual Credit card 7. Denial Management/AR Follow-up: This process inclu status checks, resolution of denied/rejected claim: 8. Correspondence Follow-up: SS con Nast to tne pyr nw Itis the process of collecting the payment from the patient when YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,2 AR TEAM: [AR Analyst (Day Shift) AR follow-up / AR Caller (Night Shift) AR Analyst (Day Shift): The AR Analysis team is responsible for reviewing and analysing pended claims as well as partial payments. IF any claim is found to have a coding etror, the AR team corrects it and resubmits the claim. AR Caller / AR follow-up (Night Shift): The AR Caller team on the other hand constantly communicates with healthcare providers, patient and the insurance companies through phone call and takes necessapyact heir feedback or responses. the skills and quality of services delivered by the AK team e\ financial health of a healthcare provider. in detefMining the Calling team: The call-centre setup where the employ act USA healthcare insurance companies in order to get the Calling can be generally classt 1) Doctor calling 2) Insurance Calli 3) Patient Calling ‘company, gets the Information on what heppened on that claim, and conveys it to the AR ‘Analyst to act on it 3) Patient Calling: the caler calls uo the patient for various reasons. When there is no response from the patient. Insurance information, Insurance coverage, Patient ‘statement, Documents needed from a patient in order to move the pended claim to the next processing stage. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,B ‘Accounts Receivables department —the backbone of Medical Billing. 3 P’s in medical billing: ‘LPATIENT, 2.PROVIDER 3.PAYOR 1. Who is Patient (Insurer/subscriber/dependent/policy holder]? Gy s fromthe provider. The person who g 2 (Other names Insurer/subscriber/dependent/poliy hol 2. Who is Provider (Doc} clinics, laboratories)? icians, SMgeonsspechnicians, hospitals, a ical services to the patient = 3. Wh jeMpsurance company)? The individbal or an organization that process the claim and pays the provider for the medical services are given to the patient.nt. (> aia Humana} YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,14 DEMO entry (Patient's Demographic)? It is the process of entering the patient details into the provider software. Demographic details to be entered ere as follows: {Patient's details (Account #, Name, age, sex,address,SSN,marit 2 Patient's Insurance details 3.COB (Coordination of benefits) 4,RO| (Release of information) 5.AOB (Assignment of benefits) G.ABN (Advanced Beneficiary Notice)/WOL (Wavies of li 7 Patient's guarantor details & Patient's Employer details is,telephone #, etc.) a. Patient Name: Entered as Last name, Fi Example: Linda K Janes can be wr \ber which is allatted to the patient by the Social Security jone number: 1e contact number of the patient including the area code. It contains a total (111-222-3333), the first 3 digits are the area code, and the next 7 digits are the phone number of the patient. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,15 Encounter process? Iis the conversation between provider and patient. Here the patient will explain to the doctor about the illness facing, ‘and the doctor will give medication to the patient. During this process, the conversation including diagnosis (DX) and Procedure (CPT) is recorded in Dictaphone as a voice file. Transcription process? SQ ‘The transcript text sheets are called Transcribed she Itis the process offgonvertig t Into a text file. Medical Coding pro Itis the process of urn service/treatment diagnosis code, and Chan Super Bill at consists of the list of services provided by a particular provider, it also. ion like appointment/visit information, CPT and ICD codes, patient information, and provider information. ric codes to the is process CPT code, It is important to note that the super bill should orly outline the medical services mentioned in the patient’s insurance plan because the insurance company will not pay for the services that fell outside the insurance plan. ‘Super Bill, also called Charge Slips, Fee Tickets, or Encounter forms. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,16 SUPERBILL TEMPLATE = = = = = ——————— ne 2 SS ES = — YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,Charge Entry process? ¥- The charge entry process is where your cleims are created. Charge entry is the process of assigning appropriate ${Dollar) value to the patient account. ¥ Once the patient information and service information has been received from the client as a scanned copy of the super bill/charge ticket, these files are downloaded from the FTP site then the following charge entry process wil happen at comple rc the $ values fo eee aren er! eric Diagnosis code (MgessMeickness)% Diagnacic enced OE ic 2 Mighin My Mors andar niimhers accigned ta particnar illness/sicknesS)gymptoms, or proeedure. Diagnosis code is d@yeidped BYQWHO'S (ICD code) Internafignal Classification of DisBase. Aig code ic Redesigned by (CMS) Centers for Medicare R. MeUitaid Servites CMS revises tRi@feularly: ICD-9-CM (ath Revision Clinical Modification} ICD-10-CM (10th Revision Clinical Modification) Example: 08.3293 denotes Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral "MS Dox 21 Up to 12 diagnoses can be reported in the header on the Form CMS-1500 paper, claim and, up to 8 diagnoses can be reported in the header on the electronic claim. Yrevaituincs Wen-vaceneeR.com INSTA/FB=VBCAREER,18 Diagnosis code volume |: This Dx codes are used to find the illness/symptoms and diseases of the patient Example:£08,3293 denotes Diabetes mellitus cue to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral Format: 01x. 106. 200.3 re Fi BRGS CR TNTUREGFLIESSCR VARY aE ALESIS DENT] | za (260.00 » 424.00 el oL +. TRA i tw [ronmen | scxwnc 1 Setanta 1 Diagnosis code volume II: E- Code: é This codes represents the External cause of injury sionalifor purposes other than for ns, pregnancies, Donar of an organ sickness/disease/illne: etc.) YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,19 Diagnosis pointer (Box# 24E)? wm 00" vy woo wv fseice| ema | cetHeecs "| MOOFIER Panter | _fbcHancer Weafas [a fe] ofa | w| can fees fe] he [us| | Mefesf a fe | fa | w wor [fe] | 1 | Slam oan a comms | orca |os o] | 7 4 oe | m fu | wo | | | {ite | i Se | O@rrirra dt ! the first diagnosis code pointer (primary diagnosis for this multiple services are performed, enter the prif letter from Ato L Although you can list up to 12 diagnosis c er of diagnosis code pointers for each service line in box 24 is lim el the 10th, 11th, and 12th diagnosis codes and their correspond the letters J, k, and L. CPT CODE: CPT-5 Digits Numeric, Alpha, Alpha Numeric Why the CPT code created? To standardized reporting of medical, surgical, anc diagnostic services and procedures performed in. patient and out-patient settings Example: 99214 used for an office visit, 90716 used for chickenpox vaccine(varicella) YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,2 CPT CODE Facts: Will all the doctors get the same payment for CPT CODE? ‘Ans: No, Reimbursed will not necessarily be the same For example, Doctor “A” may perform a physical check-up (99396) and he reimbursed $100 from insurance, The same checkup performed by another Doctor “3” he reimbursed for $90 from insurance. This is. determined by the contracts between a particular provider and the insurance company. Category of CPT codes: Category |- The existing codes consisting cf those com: port their services and procedures Category Il - Supplemental tracking code used for pe Category Iil- Temporary codes used teleport ner imental services and procedures Category | CPT CODE: The existing codes consist joviders to report their services and procedures Approved by Food 99201 ~ 99499 2) Anesthes! (00100-01999; 99100 ~ 99140 3) Surgery: 10021 ~ 69890 4) Radiology: 70010-79999 5) Pathologyand Laboratory: 2004729398 6) Medicine: 90281 - 99199; 99500-99607 YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,a Category Il CPT CODE: Supplemental tracking code used for performance measurements Provider can assign in addition to Category | code. Category I code are not linked to reimbursement. Format Four ws the Fetuer F Examples: If doctor records a patient's Body Mass Index (BMI) during a routine chet Ii code 3008F, here Body Mass Index (BMI) documented p, we could use Category Doctor use this code track specific information abct their patier tobacco-to help them deliver better healthcare and achieye bet nt. Examples: Composite Measures 0001F-0015F Patient Management 0500F-0575F Patient History 1000F-1220F Physical Examination 2000F-2050F Category Ill CPT CODE: Temporary codes that repréent neWitechnology, ind procedure. ‘and procedures they represent meet Category I criteria which includes FDA approval, Jat many providers perform the procedures, and evidence that the procedures have proven hey will be reassigned Category | codes. Conversely, Category Ill codes can be eliminated if providers do nat use them YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,2 LEVELS OF CPT CODES: Level | (DOCTOR) codes consist of the AMA's C?T code. Format: 5 Digits Numeric. Level Il (HOSPITAL) codes are HCPCS (Health Common Procedure Coding System) itincludes non- physician products, supplies, and procedures not included in CPT. Format: 5 Digits Alpha Numeric. Level Ill codes, also HCPCS local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. These codes are still luded in the HCPCS reference coding book. Some payers that coders report that Level Ill codes in addition to the Level | and Level Il code sets. However, these codes aren Format: Start with an alphabet x or Z followed by Four Digits Numeric lik Modifiers: Modifiers are added to CPT or HCPCS codes it gives additioRahinfol changing the service's original meaning tion to the Rbrvice without They are added to the end of a CPT/HCPCS cod a A — OnE OF BERMCE Sol © [° emery sce rors su 55" vy un 68 vv BAS ewa| cof BRESH OS ee wou lf foo fu fn ff a eof as | a lela fa | vce ff orf xe | 1 toe f os [a [o{ w fa |» we lm [as | | 2 49Tiee io ac Ken aE J ow | | | | a | yy iI i= 6: : ——— toretpdtd YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,23 Claim filing methods: The most common methods are two: Electronic (Claim sent through clearing house) Paper(Claim sent through post or mail) Electronic claim submission: Clectronie claims or £ laims are submitted through clearinghouses, The clearinghouse will check the claims for errors if an error is found then the claim will never send to insurance, it will get rejected, which is called clearinghouse rejections. Once the errors have been rectifigdiMmanually then the claim will resubmit, again the clearinghouse will check for errors if no error is fdlind then the claim will send to insurance by converting the claim’s format to the insurance-speci clean claim. clearinghouse, ifthe payer end found an error again the end rejections. Examples of Clearinghouses: Availity, Navient, Gateway, et Scrubber report The clearinghouse will generate the Scrul received to the clearinghouse, H@w many pas passed to the insurance conqpany.. What is the purpose, The claim scrubber fell codes and ICD-10-CM codes. The scrubber looks at the procedure code and fe to fstify the medical necessity of the procedure. YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,24 Paper claim submission: Claim sent through pest or mail ‘Submission of the CMS 1500 claim form should either be typed or computer-printed forms. Handwritten forms can cause delays and errors in processing and slow down time for reimbursement. Claim forms two types: LHCFA/CMS 1500 ( Doctor/Professional claim form ) Te Health Istaon (HFA, (CMS) form 1500 Itconsists of 33 blocks The is a medical claim form for individual doctors & practices, nurses, an we Cenuer Uf Meuicald aiid Medicare Services sve Finance Aun rofessionals, including Sw YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,2% therapists, chiropractors, and out-patient clinics. Geka 2.UB04/CMS1450 ( Hospital/Technical Claim form ): The Uniform Billing Form (UB04), The Center of Medicaid and Medicare Services (CMS) form 1450 It consists of 81 blocks The is a claim form used by hospitals, nursing facilites, in-patient, and other facility providers. A YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,specific facility provider of service may also utilize this type of form. Terminologies YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,2% Place of Service Codes (POS) POS means The Service/treatment where rendered Format; Two-digit numeric (CMS1500 block/box# 24b) POS codes maintained by The Centers for Medicars & Medicaid Services (CMS) Feamplee 21 Inpatient Hospital 22 On Campus-Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 31 Skilled Nursing Facility 32. Nursing Facility 81 Independent Laboratory etc, ORES OF BCE 7 PROGEDIRES SAUCES CH STPRUES an Se | ieaal [| eeemeneane a5" vr o_08 of feo] ela | cotrest Mt een oz | 26 | a | | 2 | a] wt | « [se {w | a Zhen | 2s | Or rc o2 {2 fa [ow] x fal] w voor [ur fe] | {fa |w{s fall » wor | [as] | —_— wi == o | 26 far | oo | m6 | a] cour a a rt l i i ji i A ne YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,2» Type Of Service Codes ( TOS }: ‘The type of service value is system generated from the procedure code on the claim and helps describe the procedure code. Format: Two-digit numeric Examples: Transaction Code list - General Type of Service: O1-Medical Care 02-Surgery 03-Consultation Transection Code List - 16-Giobal Service Radiology ‘1H-Global Service Laboratory tence VIC In-Network Provider/Contracte The provider who is contracted with the Wigurance 1y Contractual adjustment avail SS acted Provider: jth Insurence company medica ness or nur that patient have before started a new health plan Any service relate to this contin wl be denied as a Pte-exstng condition Awaiting period is available here Waiting period: For a patient’s pre-existing condition patient have to wait for some time to get the coverage, once the waiting period is over then the claim will be payable by insurance. The duration of the waiting YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,x0 period may vary from company to company. The number of years depends on the patient's age, and what the conltion is. During the waitin period the claim never payable. Capitation: Its lke a prepaid check given to the provider by the insurance company that all the services going to be done by that particular provider will never be paid again and again for each patient visit Providers are paid for each enrolled patient, or per member per month (PMPM). This s called the capitated rate or capitation premium, or in short form “cap”. Referral number: RAN (Referral Authorization Nu Block# 23 While referring, PCP will generate a "Referral numer” which has billing the claim to insurance if referral number not entered in t claim will be denied as missing "Referral number”, that Pre-Authorization: Block# 23 The provider needs to get this from the insurancs ertain services. is about to perform certain vice which is going to be a risk to the It is prior approval from the insurance cof Eee aC ean eee sear eer \ e mer ers coma | = Sepemnooon CRIGINAL REF. NO. 0906 it Ba PRIGR AUTHGRTEATICN NOGA = ud 612374 cance nOrUS ] © = = z z hemeiedice rien | suveas | oie [Rom | wus | 1 ; ae 2 | [ssf fe [us | 1sodz0] 1 | [re = ia | | zoms2| 3 |_ fw & Pre-Determination: Pre-Determination is a process of verifying the patient's eligibility for the date of service to find out whether le service which is going to be done will be covered or nol under the patient's health plan A pre-determination letter or form sent from a medical provider to insurance carrier. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,3 Advance Beneficiary Notice (ABN): This ABN should give to the patient by the provider before performing the services, Iti to inform the patient that if the insurance carrier denies the claim then the patient is responsible to pay the provider. If the provider missed getting a patient's sign in the ABN form then the provider cannot bill the patient for non-covered services. Waiver of Liability (WOL) and advance Beneficiary Not difference is ABN the term is used for Medicare recipients. Ot is used as Waiver of Liability ( WOL) Assignment of Benefits (AOB): Patien It is an agreement between the patient and indlpance ditectly to the provider. it agreeing to send payment If AOB was not signed by the me ‘ther Bayment will ROt be i be issued directly to patient. IS THERE ANOTHER) HEALTH BENEFIT PLAN? a sd to the provider. Payment will YES NO ___Myes, complete items 9, 9a, and 9d. 12, INSURED'S OR AUTHORIZED PERSONS SIGNATURE | althorize payment of medical benefits to the undersigned physician or suppier for services described below SIGNED. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,2 Release of Information (ROI): patient and provider agreement {tis an authorization given by the patient to the provider that the provider can share the patient's personal health information with others for billing purposes. ‘ppc his aso request paynentol goeerwrent Gants Aer meal e ply whoaccerts as Sgyr=nt INguF ane. are sa Coordination of Benefits (COB): Toidentiy Insurance is secondary and which one is tertiary. ich If the patient has more than one insurance pl Insurances to establish which insurance is prim payer will pay first and the secondary payer will p after the primary paid. ipdate the COB to both secondary—the primary {patient responsibility) ere e 11. INSURED'S POLICY GROUP OR FECA NUMBER @. INSURED'S DATE OF BIRTH Ex MM DD 1 YY = i | s : e) |b. OTHER CLAIM ID (Designated by NUCC) ' °c INSURANCE PLAN NAME CR PROGRAM NAME IS THERE ANOTHER HEALTH BENEFIT PLAN? [lilves Ta]NO yes compat tame 9,02, noo ' payment of mecical henefts 10 ine undersigned fysician or supplier tor services described below. SIGNED. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,2B Refund: insurance paid an incorrect payment to the provider The provider will receive a refund letter from the insurance carrier stating that insurance had paid incorrectly so the provider should return the money to the insurance company Example: Let the total billed amount of a claim be $100.00 and the specified payment for this is $80.00. The insurance pays $90.00 for the claim. Here $10.00 is paid in excess. Now the insurance requests for a refund of $10.00 which will be done as per the client specifications. Recoupment/Take-back (OFFSET): {f the provider has not responded ta the refund letter icssied by t insurance company will compensate(adjust) that particular am provider. Example: Let the total billed amount of two cla this is $80.00. The insurance pays $90. specified payment for 1s paid in excess. Now while ,OBand sets $10.00 as offset. Now the Insurance payment becomes normal as the’ jad been adjusted off. Classi ioMef Insurances: 1. Federal 2. Semi Federal 3. Commercial 4, Liability 5. Workers Compensation YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,4 1. Federal Insurance: Medicare Medicaid CHAMPUS —Tricare and CHAMPVA ‘A Medicare Insurance: Disabled people Insurance type: Federal health insurance ‘Administered by: CMS ~ Centre for Medicaid and Medicare services Medicare Eligibility: Must be a American citizen or a permanent tasid: five continuous years ‘A person should 65 years and above Permanently/Temporarily disabled person. ESRD ~ End Stage Renal Disease ‘A person who paid Medicare taxes while work! ast Wyea farters. Medicare through Spouse TFL for Medicare 1 year. Parts of Met re: There are four parts of Madicaretlbart A, Part and Part D. Part A~ Hap nt) Part B- Doctor (0 YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,35 Medicare Part A: Another name ( Hospital Coverage ) Premium free policy: People don’t have to pay a premium for Part A because an individual has already paid 10 years of social service tax under Medicare-covered employment. However, Part Aisn’t totally free. ‘Medicare charges an annual deductible each time admitted to the hospital. ‘Medicare’s Deductible changes every year. Year: 2020 2021, INPATIENT HOSPITAL DEDUCTIBLE: $1408 $1484 Medicare Part A cavers: ‘A. In-patient hospital care: (Covers Tech In-patient means Patients must st for at least one night. (whtehs usually a hospital) B, Skilled nursing facility (SNF ih patient home for an iliness or injury by trained YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,Fa ‘Medicare Part B: Another name ( Supplemental Medical insurance } ‘Not a Premium free policy. Need to Purchase the policy In-order to purchase Part 8 coverage one should have Part A active then only he can purchase Part B Medicare Part B covers: Outpatient Hospital covers professional component ( Doctor services } Durable medical equipment (DME) Home health services Ambulance services Preventive services Therapy services ‘Mental health services etc. Pays for consultation, outpatient Hospital services, and Durable Medical t ‘Mevicare Part C: Another name ( Medicare Advant we Part C = Part A+Part B riyd{Binsurance companies approved by Medicare. ‘Medicare aavanta ‘age for hospital care ( Part A ), doctor visits ( Part B), and other medi rovide all coverage in one plan which includes Part A&B covey ontinves to be provided by Part A). ‘Not a Premium free policy. Need to Purchase the olicy ‘Medicare Part A and Part B does not cover prescription drugs one should by Part D separately along with Part A in-order to cover his/her Drugs costs. Two type of coverage: PDP (Prescription Drug Plan } APD ( Medicare Advantage Prescription Drug ) YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,7 ‘A POP provides coverage of out-patient prescripticn drugs ‘An MAPD provides coverage for out-patient Medicare Part D prescription drugs -and also includes coverage of Medicare Part A (in-patient and hospital coverage) and Medicare Part B (out-patient and physician coverage). An MAPD may also provide supplemental benefits beyond usual Medicare coverage such as vision care, dental care, and more. Paella ele ee ERT e-1hO ean Peet Tee + Part Areceived + Need to Purchase + Need to automatically * Covers outpatient Purchase Provide ll + Need not purchase + To purchase part B one Coverage in one plan + Covers inpatient should have part A nee a hospital expenses + Pays for consultation, oSpiceteaT ener + Pays for Hospital, ‘outpatient Hospital Rospics core id Skilled Nursing Facility services and for re Ope and Hospice Durable medical te Z ‘equipment | then automatically Medicare will forward ry payer (consecutive payers) for processing, This is |. Mostly electronic forward happens which is called as YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,38 B.Medicaid Insurance: Poor people Insurance type: Federal health insurance ‘Administered by: Medicaid is administered by states, according to federal requirements Medicaid Eligibility The people who are below the poverty line (Poor people) fan annual income is less than the average income of an individual for a month Points to remember: ‘Medicaid is a premium free policy It is administered by state governments and the policy will bafenewed on a monthly Basis, ‘Medicaid will be the last insurance ‘No patient responsibility. Medicaid Spend down charges: I an individual average income exceeds the ity slab hen the excess amount has ‘s medical expense. DEERS: Defense Enrollment Eligibility Reporting System? DEERS is a computerized database of military sponsors, families and others worldwide who are entitled for TRICARE and other benefits. Active-duty and retired service members are automatically registered in DEERS, but they must register their family members and make sure all the information is correct to ensure TRICARE coverage. YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,Fy D.CHAMPVA: The Civilian Health and Medical Program of the Department of Veterans Affairs? ‘A person who served in US Army during war Premium free policy Ifa Veteran who rated temporarily or permanently disabled CHAMPVA provides coverage. CCHAMPVA provides overage Lu Une spouse Ur widower aid to the children of a Veteran who: The spouse or child of a Veteran who's been temporarily or permanej connected disability by a VA regional office, or isabled for a service- The surviving spouse or child of a Veteran whe died from a disability, or The surviving spouse or child of a Veteran who was af the timalbf death tempbraril permanently disabled from a service-connected.disabili The surviving spouse or child of a service misconduct (in most of these cases, family line of duty, not due to ber rs ality RE, not CHAMPVA). CHAMPVA. always the secondary pair to Medic y YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,2.Commercial Insurance: Commercial insurance is administered by privete insurance companies. Medicare Advantage: This is a government plan, is administered by private insurance companies approved by Medicare. Top Commercial insurance companies: United Healthcare Wellpoint Aetna CIGNA Humana Centene Health Net WellCare Health Plans Healthspring ‘Molina Healthcare etc. This is the insurance covera, red during work. WC Features: Dependents are not cc smployees (Workers) kind of lossto its workers during the work infections, o* injuries that are work-related Office of Workers Compensation Programs (OWCP)?, ‘OWCP administers the Federal Employees’ Compensation Act (FECA) it provides compensation. benefits to workers who got injured during work. They act as the middle man between Employer, Employee, and the WC insurance. The representatives of this OWCP are called OMBUDSMAN, YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,4, Liability Insurance: ability insurance provides protection against claims resulting from injuries and damage to people and/or property. Three Important Liability Insurance: ‘Motor Vehicle Accident (MVA) Personal Injury Protection (PIP) © Property Namage A, Motor Vehicle Accident (MVA) This insurance pay for the injury or loss that occurred due to a motor: state-owned policies. hieleaccident. It is mostly Various documents supposed to be submitted in order to get ps documents such as: Accident report from the patient Medical records from the provider FIR (First Injury Report) from the police Witness report from the witnesses. 12 No-foult states: Florida, Hawaii, Kansas, Kentucky, Massachusetts, Minnesota, Michigan, New York, New Jersey, North Dakota, Pennsylvania, and Utah. To find who is at fault will take long and costly court battles in an attempt to reduce this problem the above 12 states are adopted no-fault insurance states. YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,Collision insurance: It will typically cover events within a driver’s control, or when another vehicle collides with your car. Collision insurance can also be used toward your rental car in most cases. Example: The car crashed by hitting a tree whil driving. ‘Comprehensive coverage: It ves coverage for the damage caused by a natural disaster te wl typically cover events that in the driver's out of control while dn ‘Example: A tree branch fell on the car. Third Party Coverage: Bodily Injury Liability (BIL) Property damage liability (PDL) Bodily Injury Liability (B {or iMllsies yoweause to another driver if you are at-fault in the Bodily injury liability i Bodily injurgdoes not al CB8ts of injuries you may get in the accident. It is considered "third-par ers other drivers and passengers. C. Property liability (PDL): surance covers the cost of damage caused to others, whether you damaged others’ car, house, or any other type of personal property. Types of Plans: HMO. PPO Pos EPO YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,HMO: Health maintenance organization: Budget friendly plan. Itis one of the cheapest types of health insurance. It has low premiums and the deductible and fixed copay for doctor visits. HMO is an individual plan. In this policy, a PCP (Primary Care Physician) will be allocated. HMO requires referral# from PCP when patient referred to get treated by a Specialist. It covers only In-Network benefits, Out of network benefits not available. POS: Point-of-Service: Hybrid of HMO and PPO POS is one of the cheapest types of health insurance. It has low premiums ible and fixed copay tor doctor visits POS is an individual plan. CP (Primary Care Physician) will be allocated in POS, Kequires referral from PCP when patient referred to a Speci Both In-Network benefits and Out of network ben ‘but fewer patient responsibilities jer premiums than HMO and POS plan YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,EPO: Exclusive Provider Organization: Lower monthly premiums but a higher deductible If you're looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan. EPO is a group plan PCP (Primary Care Physician) and Referral not needed. A patient can directly meet Specialist It covers only In-Network benefits, Out of network benefits not available. Pond Primary Care Physician (PCP) required? Orders of Insurances: Primary Insurance: The insurance company which pays fist. Secondary Insurance: This pays balance after the primary insurance which may include co- Insurance, deductible, and non-covered under primary. Tertiary Insurance: If secondary insurance denies the claim for some reason then the bill can be submitted to tertiary. Wen-vaceneeR.com INSTA/FB=VBCAREER,Deductible: ‘A deductible is usually a fixed dollar amount that the patient has to pay from his pocket before the insurance starts to cover Depending on the insurance plan the deductible can range from $0 up to thousands of dollars. Generally, Plans with lower monthly premiums have a higher Deductible, Medicare’s Deductible changes every year. Yea 2020 2021 INPATIENTHOSeITAL oeDUCTis.<; Sa Co-Pay: Aco-payment is the smallest fixed amout rvi 1id by a patient to the provider before receiving the spectied 5 Generally, Plans with lower ner copay. Co-nayments such si Co-Insufgnce: Ftion or % oPthE medical cost that patient oavs after the patient's deductible has Coinsurance is a eligible costs that ad ying that patient and the patient's insurance carrier each pay a share of P t0 100 %. For example, Insurance pays 80% and the remaining 20% is patient responsibility as coinsurance YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,a claim will process in terms of benefits? Example: BS Decuciie 1000.00 a Out of pocket expenses $5000.00 elnsurance(20%) 400020 % = $800{Coinsuance) I sier reducing detuctibe insurance starts to pay ite $8000 -§1000= $4000.00 Deductible + coinsurance = $1800.00 (Patient Pays) 4000x805 = $3200.00 (Insurance pay) Out of pos ket maxignurmimit (Deddactiblese,Co-payments + Co-insurances) Most the patient have to pay felicover @dliservices jn aplan year. After spending this amount on deductibles, co-paym@ntsland co-tsurancés fori shetwork care services, the patient's health plan pays 100% of the Eats of cored benefits eer eee Deductible $1000.00 Out of pocket expenses $5000.00 Coinsurance(20x) 4000 X20 % = $800 (Coinsurance) Deductible + Coinsurance = $1800 00 (Patient Pay) Yrevaituincs Wen-vaceneeR.com INSTA/FB-VBCAREER,Stop loss clause: (Same like Deductible) ‘top-loss insurance also known as excess insurance, It is a product that provides protection against catastrophic or unpredictable losses, Its purchased by employers who have decided to self-fund their employee benefit plans, but do not want to assume 100% of the liability for losses arising from the plans. Under a stop-loss policy, the insurance company becomes liable for losses that exceed certain limits called deductibles. For example: If an employer elects that their maximum liability per person on their benefits plan for that policy year be $10,000 and a specific claimant exceeds that liability $10,200, the stop-loss policy will reimburse them for claims over that a There are two types of Self-funcled insurance: Specific stop-loss (Individual): Covers exces snouse and children on an incvidual basis, Aggregate (Entire group): covers claims wher ed by the insurance: specified amount determi Timely filing limit (TFL): It isa time limit given by insdance’ provider failed to send a clair claim as “Late filing” claitas for a ‘claims exceed a year. .bmit a claim for processing. If the it then insurance company will deny the ‘ARP TSWonths ‘Advantage Care Glonths ‘Advantage Freedom 2Years Aetna timely filing 120 Days ‘Ameri health ADM Local 360 Tear: ‘American Life and Health T2Wonths “American Progressive TYear ‘Amerigroup 0 Days for Par Providers or I2 months for Hon Par Providers YEeve.uines “Ameriheaith ADM TPA Tear ‘AmeriHealth NJ & DE 60 Days ‘Arbazo 180 Days Bankers Life TSWonths Wen-vaceneeR.com INSTA/FB=VBCAREER,BCBS timely filing for Commercia 180 Days from Initial Clains or if its secondary 60 Days \/Federal fromPrixary E08 BCBS COVERKIDS 120 Days. ‘BCBS Florida timely filing T2Wonths BeechStreet 0 Days Benefit Trust Fund T year fron edicare E08 Blue Advantage HMO 180 Days Blue Cross PPO TYear Blue Eecential 180 Dave Blue Premier 180 Doys Blue Shield timely filing Tear Blue shield High Mark 60 Days Cigna timely filing (Commer tans) Cigna HealthSprings (Medicare 0 Days for Por Providers or 180 bays gépNon Par Providers 120 Days Plans) Citrus TYear Coventry 180 Days; Evercare 0 Days First Health Bont GHI Tear Great West Days Great West ths Healthcare Partners 0 Healthnet HMO 0 Days Healthnet PPO. 0 Days, Horizon Nd Plus Humana 180 Days for Physicians Humana Months TLWU 3 Years Keystone Health Plan East 60 Days Cowl 831 Healthy Trew ‘Magna Care Months: Marilyn Electro IND. Benefit Fun | | Year a Medicaid 9% Days Medicare Tear: ‘Mega Life and Health TS Wonths ‘Memorial IPA 0 Days ‘Monarch IPA 90 Days Mutual of Omaha Tyear| NAST 2Years ‘Omnicare IPA 90 Days ‘One Healthpian TSWonths YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,50 Operating Engineers Lear Pacific Health Care IPA 0 Devs Pioneer Medical Group Days Polk Community Health Gare 180 0ays Prospect Medical Group 0 Days PUP 180 Days Quality Health Plan Teor ‘Secure Hoizons 0 Days Sun 180 dave Tricare T2Wonths UFCW Tyear UHC Community 20 days Unicare 2b Months United Health Care = UHC COMM | 40 Days ERCIAL Veterans Admin 0 Davs Vista 120 Days Wellcare Zenith Medi-Cal Medicare Pre-Audit/ P Claim adjudication: ‘Once the claim reached the insurance company, aspecific department called Claim adjudication department they analyze the claim and decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,st Five steps in claim adjudication process: The initial processing review. The automatic review. The manual review. ‘The payment determination. The payment. Five steps in the adjudication process. pl 5, Invalid or r, Mismatch of service, and 4. The initial prorescing review: Inrnrrect patient name, missing DX, Wrong plan or subscriber identification nu patient's gender 2. Ihe automatic review: Patient Eligibility, Absence certification, Duplicate claims are submitt code, The services are medically necessary 0! 3, The manual review: Medical the medical documentati YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,52 After the adjudication process, the decision taken during that process is communicated to provider and patient using the statement called EOB The most important thing to keep remember is an EOB is NOT a bill £08 contains: ‘Member information Patient acenuint number Service codes: Total amount: Not covered amount: Reason code description: Covered by plan Provider name Claim number Date of service Deductibles and Co-payments: Total net payment: yeck @ihount- Total Patient Responsibility: Checks Details: Payee's name, check number, a Double Click this file on to view E08 ter YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,os 53 Sehow your benefits are working for you wth this esyto-understand document that shows you the costs associated with the medial care youve aceved, ‘When a claims fled under your GGNA benefits plan you get an Explanation of Benefits (EOS). Because we know health are ‘expenses canbe confusing, we've simplified the language and summazed the mastimportant information about the lim, eeeeceee ona Cnet acon Compny ‘overview how yourbenefts re Soke eee | EO wassubmitedwhatsbeen paid, |B Savane oe SF crrweere uaa wis Explanation of benefits Seen owen ovo an hee ee patsindectaiaeie; _|__4 Sunmaryof cli frserces on my 17, 2009 fone vy oem Wen pet asst —————— fares eas soe Semen Sepang bes au Deemer eamaatuone dst = mtr mun mn ‘eran amaay an — weet on i coeomecte Sate pnd cty ade ano pay yr, it’s time to feel better YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,sa ‘The Claims Detail page follows the Glossary page. Here, youl find: Thedolramountand peretane GNA pai toward the covert Theporon of cnerdengeses you espns paying Fer example your moun minsanycpay/eduableyoerspnsbiefo.—_OGNAplan covers 90 ofthe cover amount, youpy the main 1% a uum vatweesn || =a or rhs eee an Bieta | aac Se ee ha need know ormy nest cin (oldies oon oe ier epee ‘pt armel ec pneu iemteaafer noah spear ne: (ep eles shone he pce YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,55 Payment Posting: After insurance completes the claim processing, the payment will be issued along with an Explanation of Benefits ( EOB ) to provider pay to address. The payment will receive in many ways paper check, eft, credit card, etc, Once the payment is received successfully by referencing the received E08 that payment details will be posted in the patient account. If the payment posted correctly and there is no other balance in that patient account that particular claim will he serned cut which meanc the claim uae enmplaterd Billed Amount: The amount charged by the provider for the service rendered CA, e a L 5 Ta ARES e F S. Lal 7 eee Nncrioes oe fa] rencennis cores [ee sounoes | li [etl ot| | encurenee fise [auf a fous 450420] 1 | [ve 7 fe {| 1 20132 [ne car Ue sgertassaygyr fo tora rae | D]z mount ea |iso reas Les [Jno s 170152 | s 0} Of lameness { (GRINFCRMATION a \VAILUNGS CLNIC 51 Hollywood Peway Allowed Amount: It is the maximum amount allowed by the insurance company for the service rendered by the provider. This amount is based on the provider and payer contract which was discussed and listed in the provider fee-Schedule. YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,56 Fee-Schedule: It isa list of charges for health care services. Providers keep fee schedules in their offices to specify the amount of compensation they wart for providing selected services. Example: Labor Epidural codes 01967 & 01968 are reimbursed on a flat rate. Reference: mmis.georgia.gov 01967 AA $248.50 OK $82.83, oy $82.83 Ox $165.66 u $246.02 Ok $133.33 oy $133.33 ax $256.66 au $396.00 YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,37 Contractual Adjustment: The contract between provider and insurance agrees to discount (Write off) ‘The difference between what the provider billed and what the insurance plan allows. The patient is not responsible. The provider should write-off the difference amount. Claim deta Important short forms used in m@@ical Mjjline EOB - Explanation of benefits COB -Co-ordination of Benefits MSP - Medicare as a Secdhdary Pay POS - Place of servic TOS - Type of Servi DOS - Date uf ICD - 9-Internat ical Glassification of Diseases and Related Health n Procedure Coding System HIPAA urance Portability and Accountability Act RBRVS - The ce Based Relative Value Scale RVU - Relating Value Unit CHAMPUS - Civilian Health and Medical Program of the Uniformed Services CHAMPVA - Civilian Health and Medical Program for the Veteran Administration NCCI: National Correct Coding Initiative ESRD - End-Stage Renal Disease FICA - Federal Insurance Contributions Act HICN - Health Insurance Claim Number YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,se COBRA - Consolidated Omnibus Budget Reconcil EGHP - Employer Group Health Plan UCR - Usual, customary and reasonable PCP - Primary care physician HMO - Health Maintenance Organization PPO - Preferred Provider Organization TPA- Third Party Administrators HIPAA- Health Insurance Portability and Accountability Act ‘ABN: Advance Beneficiary Notice of Non-coverag ADA: American Dental Association AU: Administrative Law Judge AMA: American Medical Association ANSI: American National Standards Ifstitul ASA: American Society of Anesthesiologists ASC: Ambulatory Surgical Cen’ BBA: Balanced Budget Aci CAH: Critical Access Hospi VS CCI: refer to NCCI CCN: Correspond CNM: Certified Nurse Midwife CNMW: Certified Nurse Midwife CNS: Certified Nurse Specialist CPT: Current Procedural Terminology CRD: Chronic Renal Disease CRNA: Certified Registered Nurse Anesthetist CWF: Common Working File DHHS: Department of Health & Human Services YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,Ey DME: Durable Medical Equipment DOB: Date of Birth DOS: Date of Service DX: Diagnosis/Diagnoses ECF: Extended Care Facility EDI: Electronic Data Interchange EIN: Employer Identification Number (Tax ID) EKG: Electrocardiogram E/M: Evaluation and Management EOB: Explanation of Benefits ERA: Electronic Remittance Advice ESRD: End Stage Renal Disease FDA: Food and Drug Administration HICN: Health Insurance Claim Number HIPAA Health Insurance Portability and Accountability -9th\Edition HMO: Health Maintenance Organization HPSA: Health Professional Shortage ICD-9-CM: Internal Classification of Dise: ICU: Intensive Care Unit LMRP: Local Medical Re MSP: Medicare Sei RA: vice SNF: Skilled Nursing Facility SSN: Social Security Number TOS: Type of Service YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,8 Denials / AR Scenarios Claim denied for missing/invalid AUTHORIZATION:(BLOCK 23) ‘Questions to probe with Payer Rep: Claim received date? Claim denied date? ‘Check system for auth is available or not if found give that to rep and reprocess ‘Check claim image if auth# found in Block#23 give that to rep for reprocess If auth# not found in anyway, ask rep is Retro authorization is possible or not?, If retro auth is possible then ask the procedure to get retro auth. een net en ent cena eeeer eA ertrerpren Claim# and Call reference# Thank you. ***Note: If the Pos is 23 is used then no need to get the auth since service, on call ask rep to reprocess. RENDERING PROVIDER: Provider who provides actual seqyice. REFERRING PROVIDER/Prima Provider who provides lable or not if found give that to rep and reprocess found in Block#23 give that to rep for reprocess Yovay, ak 1ep wlial is PCP (priitiaty vate pliysivian)) reine ain \d get the corrected claim address and time filing limit Thank you. **4Note: PPO & EPO plan doesn't req reprocess. a referral, if the patient plan is PPO & EPO ask the rep to YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,oy First understand what is inclusive: Inclusive/Bundled is a payment method that combines minor surgeries with principal procedures when performed together. Example: If an x-ray for both right shoulder and left shoulder was taken on the same day (00S) and we billed with cpt code 73030 (both right and left side). Again, there is need to take another x-ray on left side so we took separate x-ray and billed cpt code 73020. In this case we will receive denial stating 73020 x-rays for left shoulder has already included with 73030, Claim denied date? ‘Ask the rep to which Primary CPT code it was included with, get that Wfimary CPT code from the rep, and verify that primary CPT cade was hilled on the cam askan which DOS this primary CPT code was billed with? Can we send the corrected claim with the appropriate mos claim mailing address and TFL? if the corrected cl 1e appeal address and appeal 1H? Claim# and Call reference Thank you. to REPROCESS since this is “Distinct jan may need to indicate that a her services performed on the same Claim denied ‘Ask rep what is the normal TFL? Check the received date, if the claim received within the TFL specified by the rep, then ask for reprocess If the received date was exceeded the TFL then ask for the appeal address and appeal TFL Appeal with proof of timely filing limit (PCTFL) Claim and Call reference Thank you. ‘***Note: POFTL can be anything that we have when we had submitted the claim within YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,a time frame Usually, POFTL will be a clearinghouse report. Claim received date? Claim denied date? ‘Ask rep what is the secondary allowed amount? Check the primary paid amount in primary E08, if primary paid mot then adjust the claim, If primary paid is less than secondary allowed tl to reprocess, Claim# and Call reference Thank you, SS 'an secondary allowed Claim received date? Claim denied date? ‘Check system for primary el resubmit the claim witlijarimal Hf we are not having prim primary payer pr phone numb Claim# and Call Thank ou. lary eo} then ask the mailing address and TFL to who is primary, then ask rep about rimary payer member id, and primary payer ~ Questions to probe with Payer Rep: Claim denied date? ‘Ask rep why this is medically not a necessity? ‘Ask rep can we submit a corrected claim by changing the Diagnosis code? If yes ask corrected claim mailing address and TFL. If not possible then ask for an appeal address and TFL. Claim# and Call referenceit Thank you. “Note: Medically not necessity usually denotes Dx cocrections so if the corrected claim is possible, we YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,can resubmit by changing Dx code. la corrected claim not possible we need to apeal with complete medical records to show how medically necessary this service was. ***For Medicare claims ask rep for any LCD/NCD# available? COB: If patient more than one insurance then patient need to update the COB to show who is brimary and whois secondary and whois tertiary ~ Questions to probe with Payer Rep: Claim received date? Claim denied date? Ask ep, when the Patient last updated the CO8? Check it the DOS i es within 3 year trom the last updated (reprocess only a possibility, not a compulsion) Ask rep did they send a letter to the member regard) letters sent so far and get those dates also ask did, thi member, not askto send another letter (Mt Wf letters sent out already then askhow the member service dept phone#, here memt in Ask the rep can we bill the patient? Claim and Call eferencet Thank you fen ask for repro ‘ep will provide update the COB) re before you start a new health care plan. een the start and end date of the waiting period, then ask did they send any not ask to send letter regarding pre-existing denial Now ask can we bill the patient? the DOS is not lies between the start and erd date of the waiting period, then ask the rep to reprocess. Claim# and Call reference Thank you. Waiting period: Its the period during which e member cannot claim for some medical benefits. Member should wait for a specified amount of time before making @ claim. ‘The duration of the waiting period may vary from company to company. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,+ Questions to probe with Payer Rep: Claim received date? Claim denied date? ‘Ask rep, is non covered under patient plan or provider cor If under patient's plan then ask what 1s non-covered in patient? Hf under provider's contract then ask what is nor write-off. Claims and Call referencett Thank you. “Note: If claim denied under patient pl ‘and ask can Well sd to secondary insurance then we Before billing the claim Ifo other ligibility for the secondary payer. member idif, policy effective, and termed date. Ifno other active policy found then and ask can we bill the patient? Claim# and Call reference# Thank you. "Note: Check for other insurance is available or not if other insurance found then check eligibility for that insurance and if patient is active for that insurance then make it as, primary and resubmit the claim. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,~ Questions to probe with Payer Rep: Claim received date? Claim denied date? ‘Ask rep what is the DOS that the main surgery perfor ‘Ask the rep what is the Global period? If the DOS lies within the Global period then ask’ appropriate modifier? If yes, then get cor claim not possible the ask for the appeal If the DOS is not lies within the Global ®erio« Claim and Call referencett Thank you. \d aorr im with an and TFUjit the corrected to reprocess "Note: When the DOS lies in the! should be provider write off Before write off ass arification because we can send a corrected eleim service is independent of mein surgery. ‘year? Also, ask how much met in that so far? {It balance dollars is available ask to reprocess) If itis under a visit plan then ask how many visits are allowed for this patient for a calendar ‘year? Also, ask how much met in that so far? {if balance visits are available ask to reprocess) ‘Ask rep on which DOS patient has met the maximum benefits limit Now ask can we bill the patient? Claim# and Call referenceit Thank you. s+ *Note: If patient has active secondary insurance on COS then bill the claim to secondary. no other active insurance found on DOS then bill patient. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,How duplicate happen: Iftwo claims are submitted with the same informatigilike (Same DX, CPT, MODIFIER, BILLED AMOUNT, PROVIDER information, etc). If any one of these details is differing then you can inform the differences you found rep and ask to reprocess th@lduplicate claim. Questions to probe with Payer Rep: Claim received date? claim? (mostly it «will come as a new claim, suppose if rep che« ‘a corrected claim then the denial is incorrect so ask the rep, Verify with the rep all these details are sa IER, BILLED AMOUNT, PROVIDER information, ete) Ifit is same then ask about the ori Thank you. Note: Hf the original claim was iF it is in the process then allow some more days, fit for then question about that specific denial scenario, Claim received date? Claim denied date? ‘Ask the rep the date “from when the provider is out of network"? ‘Ask the rep “may | know the patient policy plen type”? (HMO, PPO, POS or EPO)? if the patient plan is PPO ask the rep to reprocess.. I the patient plan type is other than PPO then ask the rep can we bill the patient? Claim# and Call reference# Thank you. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,+ Questions to probe with Payer Rep: Claim received date? Claim denied date? ‘Ask the rep “may | know which Dx code is inconsistent with CPT"? now check the patient's entire claims history if this same CPT and D) received any payment previously? If payment received previously with the same CPT and Dx cod about that previous paid DOS and ask the repto reprocess If no payment was recelved previously then ask "Can we s appropriate Dx code If yes then get the corrected et the appeal address and TFL. Claim# and cal reference Thank you. TT Note: Claim assigned to coding team to r@yjew once re’ponse send corrected claim ived with correct Ox code then ' history if this same CPT and modifier combination has Ino payment WasIreceived previously then ask “Can we submit a corrected claim with the appropriate modifier?” If yes then get the corrected claim mailing address and TFL. If no then get the appeal address and TFL. Claim# and Call reference ‘Thank you. Note: Claim assigned to coding team to review once response received with correct Modifier then send corrected claim YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,received date? Claim denied date? ‘Ask the rep “how many units are allowed for this CPT code”? ‘Ask the rep “units are allowed per day or per calendar year”?, Units given by rep) ‘Check your claim if we have billed more than the allowed ‘an appeal”? If appeal possible then get the appeal mailing addre: CClaim# and Call referencett Thank you. 4Note: Appeal with medical records XX Non-Denials / AR Scenarios OY YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,ttis an adjustment when the insurance company previously paid incorrectly to the provider (mostly itis ike an over-payment) The offset can be taken on different patients under that provider. ~ Questions to probe with Payer Kep: Claim received date? Claim processed date? ‘Ask the ren “may | know the reason, why it was applied towards offset? ‘Ask the rep may | know the allowed amount for this claim? ‘Ask the rep “is there any patient responsibilities on this claim”2(Get thy ‘Ask the rep “how much the Offset amount”? ‘Ask the rep “offset made on same patient account or different patier ‘Ask the rep “can | get the over-paid patient accounts, checkt ‘Ask the rep “could you please fax the E08? if not then ask tend the EOB to the pi mailing address. Claimi and Call reference ‘Thank you **Note Once the EOB received then send it for p resp to bill patient) ider pany thet all the services going to in for each patient visit. (Get the start and end date of Cap neriod) fod then this claim should be write-off I the DOS is not tion period then ask the rep to reprocess aid the get the managed care plan details like payer name submit to managed care plan) ***Note: For managed care plan: ‘Medicaid has the same member id so we can bill under the same member id ‘Medicare has different member id so need to find out the correct member id. Other payers: the claim needs to adjust with client approval YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,+ Questions to probe with Payer Rep: Ifthe rep says no claim on file, then ask ‘What is the correct mailing address and electronic payer id? ‘What is the timely filing limit to submit the claim? ‘Ask the rep “may | know the patient policy effective date and termed date”?(sometimes patient policy already termed at that time claims cannot be reached to the payer) Note: Hf patient policy is not active then contact patient for active payer inf@fmation. If no active payer on this DOS then bill patient \Very important point for Freshers to remember: Please don't ask the claim# Claim received date? théfp “may | the reason for delay” eee Allow some YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,n Claim paid date? ‘Ask the rep “what is the allowed amount"? ‘Ask the rep “how much the claim paid”? Ack the rep “ie there any patient reeponeil ‘Ask the rep “Paid thru Check or EFT” ‘Ask the rep “may | know the check#” ‘Ask the rep “the check is single or bulk?” ‘Ask the rep “what is the bulk amount” ‘Ask the rep “check paid to which addrass” ‘Ask the rep "Do you have a cash date" (if the paid date is mre than 30 days then askifpr cash date, if not more than 30 days don't ask) ‘Ask the rep “Could you fax the eob” CClaim# and Call referencett Thank you. “Note: For EFT transaction get the transaction id, online transaction the check sent toa iy” dress, since EFT is an Check paid to correct addre ‘ask to do “check trace’ YEeve.uines WEB-VBCEREER.COM INSTA/FB=VBCAREER,‘A deductible is usually a fixed dollar amount that the patient has to pay from his pocket before the insurance starts to cover. Depending on the insurance plan the deductible can range from $0 up to thousands of dollars. Generally, plans with lower monthly premiums have a higher Deductible. + Questions to probe with Payer Rept Claim received date? ‘Ask the rep “may I know the allowed amount” ‘Ask the rep” how much is applied towards deductible” ‘Ask the rep “may I know the patient’s annual deductitle amoun ‘Ask the rep “the claim processed to in-network deductible or dUt-ORnets deductible” ‘Ask the rep “may | know how much patie! Claims and Call reference Thank you. “Note: Once the EOB received then seni If the patient has a secondary paye! no other payer availabl posted as of this DOS” F postin 105 then Sabmit the claim to secondary. im to the patient once the deductible YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,n MOCK NON COVERED SERVICE: 1. Sandy: Thanks for calling this is Sandy, how may !help you? a ee ea ee eee eee eee status fora patient ‘Sandy: Which Doctor's office you calling for? James: | am calling for General Orthopaedic associates Sandy: What is your telephone number? James: My telephonet is 800-999-9999 Sandy: What is the patient's SSN (social security number)? James: The SSN is 123-456-789 Sandy: Could you please hold for a moment so tha | can fillithe Patient recor James: Yes, please! Sandy: What is the patient's name and DOB? 2.James: The patient name is Linda Far and DOB is W:26-1' Sandy: What is the DOS you checking James: The DOS is 12-10-2020 Sandy: What is the billed amout ed for non-covered service. er patient plan or provider contract? Sandy: Non covered as per Patient plan and the patient plan does not cover OON benefits James: What plan does the patient have? Sandy! Sandy: Let me find that James? James: Okay Sandy: James the patient plan is HMO 4,James: Okay Sandy thanks for that information, could you please Fax the eob? Sandy: Yes, what is your FAX#? James: The faxit is 842-543-6789 and you can put sttention as my name JAMES Sandy: Okay James the fax request has been submitted and it will be received within a day James: Thanks Sandy what isthe claim? YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,a Sandy: The claim is 884455 James: Is there any reference # for this call? Sandy: Yes, James itis 0285, James: Thank you so much Sandy you are very helpful to me today and you have @ Sandy: Thanks James it’s a pleasure talking to you and you have a good day. bye... bye, day! 6.Sandy: Non covered as per Patient plan and the patient plan does not cover ON benefits James: What plan does the patient have? Sandy! Sandy: Let me find that James? James: Okay Sandy: James the patient plan is PPO James: Sandy as per Patient plan type that covers out of networ for reprocess Sandy: James yes you are right, let's make a note ef it and James: Thanks Sandy Sandy: You are welcome James! days for review. James: Thanks Sandy what is the claim? Sandy: The claim is 884455 James: Is there any reference # for this ca Sandy: Yes, James itis 0285, James: Thank you so much 1nd I sent it bac today and you have a nice day! hhave a good day. James: Okay this code? Sandy: Okay Id you please hold for a moment will check some additional information on 10.James: Sandy thanks for been on hold, | realy appreciate your patience, upon checking the billing summary ofthis patient we have received payment for this code under this same provider on different DOS, could you please verify that Sandy: yes, please provide me that DOS James: Its 10-30-2020 Sandy: Let me check this DOS James, so pls be on hold James: Okay sandy YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,% Sandy: Sandy at that time on dos 10-30-2020 provider have the same contract but it got paid so let me send this claim back for reprocess James: Thanks, sandy Sandy: You are welcome, | sent it back for reprocess so please be allow 15 business days for review. James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James it’s a pleasure talking to you and you have a good day. bye... bye, 12 James: Sandy thanks for been on hold, | really appreciate your patienc®;upon checking the billing summary of this patient we have received payment for this code hi ron different DOS, could you please verify that Sandy: Sorry James we cannot compare claims so I cannot send Back for James: Okay sandy can we send an appeal? Sandy: yes you can! James: The appeal address is PO BOX 740805 AtlantaiGA 303; James: What is the timely filing limit for appeal? Sandy the TFL is 120 days from the date of der James: Thanks Sandy what isthe claim? Sandy: The claim is 884455 James: Is there any reference # for this ca Sandy: Yes James it is 0285 James: Thank you so much Sandy: Thanks James its a ple a have a good day. bye. bye.. James: Sandy: James: Sar Jame Sandy: James: Sandy: James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you end you have a good day. bye.. bye. 4LSandy: Thanks for calling this Is Sandy, how may help you? James: Hi, my name is James, | am calling for Doctor's office and | would like to check the claim. status for a patient Sandy: Which Doctor's office you calling for? YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,% James: | am calling for General Orthopedic associates Sandy: What is your telephone number? James: My telephonet is 800-999-9999 Sandy: What is the patient's SSN (social security number)? James: The SSN is 123-456-789 Sandy: Could you please hold for a moment so that I can pull the patient records? James: Yes, please! Sandy: What is the patient's name and DOB? 2.James: The patient name is Linda Far and DOB is 11-26-1995 Sandy: What is the DOS you checking for? James: The DOS is 07-26-2020 Sandy: What is the billed amount on this claim? James: The billed amount is $1500.00 Sandy: Could you please hold for a moment so that | can pull up thaelaim: James: Yes Of cour: Sandy: Thanks for being on hold James the claim was denied? James: Okay may | know the claim received date? Sandy: The claim was received on 08-15-2020 3,James: And what is the denial date? Sandy: The denial date is 08-22-2020 James: May | know the reason for the denial? Sandy: Claim was denied for no authorization on James: Could you please hold for a mo Sandy: Okay! James: Thank you so much for Sandy: The TFL for appeal is 365 days from the date of der James: Okay what isthe claims? Sandy: The claim is 98745 lames: And what Sandy: The call eft is 8578, James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you end you have a good day. bye.. bye. 6.James: Thank you so much for holding | really apareciate your patience! "Sandy upon checking | the call reference#? YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,7 found the POS we have used is “23” which denotes this is an “emergency service” so this couldn’t be denied as no auth on file, could you please check it? Sandy: Let me check that James? James: Okay Sandy: James you are right, the POS you have use¢ is 23 since this is an emergency service | am sending this claim back for reprocess and please be allow 45 business days for the review! James: Thank you so much Sandy and what is the claim? Sandy: The claim# is 98745 James: And what is the call reference? Sandy: The call reft is 8578. James: Thank you so much Sandy you are very helpful to me today and you have @ nice day! Sandy: Thanks James its a pleasure talking to you and you have a good di bye.. bye.. “7Afauthil found in your system now what will you do? 8.James: Thank you so much for holding | really aporeciate your patienc uponchetcking found auth in my system, can | verify that with you? Sandy: Yes James go ahead? James: Thank you and the Auth is AB765432 Sandy: James can I put you on hold to verity it James: Sandy take your own time! Sandy: Thank you, Jamesl...James tha given i valid for this Dos. James: Sandy can you please ser Sandy: Okay let me take a note James: Thank you! Sandy: Thank you, James! | ha review James: Thank you! nti 10.James: Can we get a retro authorization in this case? Sandy: Yes James retro auth is possiblel James: Okay Sandy how could we get the Retro authorization? Sandy: Yes you can call the authorization department at 187-845-7892! James: Okay what is the claims? Sandy: The claim# is 98745 James: And what is the call reference#? Sandy: The call reft is 8578. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,7% James: Thank you so much Sandy you are very helpful to me today and you have @ Sandy: Thanks James its a pleasure talking to you end you have a good day. bye.. bye.. day! will you do? 12.James: Thank you so much for holding | really appreciate your patience! “Sandy upon checking | found the same CPT code was paid previously without any authorization# can you please verify that? pale yaaa anata att eter James: The previous DOS is 01-22-2019 ‘Sandy: James can | put you on hold to verify it? James: Sandy take your own time! Sandy: Thank you, Jamest...lames thanks for being on hold | verified and paid previously without any Auth James: Sandy can you please send ths claim back for reprocess Sandy: Okay let me take a note onit and send this claim back fo James: Thank you! ‘Sandy: Thank you, James! | have sent it back for regrocess af James: Thank you so much Sandy and what is. Sandy: The claim is 98745 James: And what isthe call reference ‘Sandy: The call refit is 8578. James: Thank you so much Sand ‘Sandy: Thanks James its a pleast bye.. bye today and you have a nice day! a good day. 14.James: cannot find ing | really appreciate your patience! “Sandy | upon checking | 1n you please check whether any hospital claim was received Sandy: James | nd one hospital claim on this DOS James: Okay Sandy caf you please check any authorization in that hospital claim? ‘Sandy: James yes | have found one AUTH# IN HOSPITAL CLAIM, James: Could you please send this claim back for reprocess with that Auth#, Sandy: James | can send but | am not guaranteed whether your claim will be payable or not! James: That's not a problem, Sandy, you can sendit! Sandy: Okay let me take a note on it and send this claim back for reprocess! James: Thank you! Sandy: Thank you, James! | have sent it back for reoracess and please allow 4S business days for review James: Thank you so much Sandy and what is the claim#? Sandy: The claim#t is 98745, YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,~ James: And what is the call reference#? Sandy: The call reft is 8578. James: Thank you so much Sandy you are very helpful to me today and you have @ nice day! Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye.. 1LSandy: Thanks for calling this is Sandy, how may help you? James: Hi, my name is James, | am calling for Doctor's office and | would like to check the claim. status for a patient Sandy: Which Doctor's office you calling for? James: | am calling for General Orthopedic associates ‘Sandy: What is your telephone number? James: My telephonet is 800-999-9999 Sandy: What is the patient's SSN (social security number) James: The SSN is 123-456-789 Sandy: Could you please hold for a moment so that ull he pati James: Yes, please! ‘Sandy: What is the patient's name and DOB? 13% 2James: The patient name is Linda Far@@pd DOB is 18e26- Sandy: What is the DOS you checking for James: The DOS is 01-26-2021 Sandy: James: Sandy: Sandy: Sandy: reason for the denial? Sandy: Claim was: for the DX code is incorrect for the CPT code, James: Could you please provide me the Dx code? Sandy: The diagnosis code is 294.0 James: Could you please hold for a moment; | will earch this diagnosis code in my system? Sandy: Okay! S.James: Thank you so much for holding | really aporeciate your patience! "Sandy, can we send a corrected claim with appropriate dx code? YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,Sandy: Yes you can James: What is the corrected claim address? Sandy: Yes the corrected claim address is PO BOX 30432 SALT LAKE CITY UT 84130-0432. James: What isthe timely filing limit for corrected claim? Sandy: The TFL s 90 days from the date of denial! James: Okay what is the claimt? Sandy: The claim# is 98745 James: And what is the call reference#? Sandy: The call reft is 8578. James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye. James: Thank you so much for holding | really appreciate, Claim history | found this same Dx and Cpt code combinati OS, could you please verify that? Sandy: Yes can | get that DOS? James: The previous DOS is 07-15-2020 Sandy: Please be on hold James James: Okay! ‘Sandy: Thanks for begin on hold James, | so lam sending this claim back James: Thank you so much Sandy: The claim# is 98745 James: And what is th dng the ‘on previous bination have been paid already )w 45 business days for the review! ry helpful to me today and you have a nice day! you and you have a good day. James: Hi, my nai status for a patient Sandy: Which Doctors office you calling for? James: | am calling for General Orthopaedic associates Sandy: What is your telephone number? James: My telephonet is 800-999-9999 Sandy: What is the patient's SSN (social security number)? James: The SSN is 123-456-789 Sandy: Could you please hold for a moment so that I can pull the patient records? James: Yes, please! Sandy: What is the patient's name and DOB? smes, | am calling for Doctor's office and | would like to check the claim YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,a 2.James: The patient name is Linda Far and DOB is 11-26-1995 Sandy: What is the DOS you checking for? James: The DOS is 04-02-2020 Sandy: What is the billed amount on this claim? James: The billed amount is $1500.00 Sandy: Could you please hold for a moment so that I can pull up the claim? James: Yes Of course! Sandy: Thanks for being on hold James, the claim was denied? James: Okay may | know the claim received date? Sandy: The claim was received on 04-18-2020 3uJames: And what is the denial date? Sandy: The denial date is 04-22-2020 James: May | know the reason for the denial? Sandy: Claim was denied for the referral is missing/absent. James: May | know what plan does the patient has? (HMO, PO, Sandy: The patient type is HMO James: Could you please hold for a moment; | will search Sandy: Okay! James: Thank you so much for holding | really app referral in my system could you please verify dames: Thank you so muc in my system could you plea Sandy: James could yo ience! “Sandy, | have found a referral ‘As I checked the referral you gave found itis valid and active im back for reprocessing with that referral? i back for reprocess, sv please hold for e moment! ir own time Sandy! >° being on hold, I sent this claim back for reprocessing, and please be allow 45 James: Thank you so much Sandy and what is the claim#? Sandy: The claim# is UASS823 James: And what is the call reference#? Sandy: The call reference is my name and today’s date James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you end you have a good day. bye.. bye. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,James: Thank you so much for holding | appreciate your patience! “Sandy, | cannot find any referral in my system so do you see any referral on file? Sandy: No James James: Sandy can you please check any hospital claim on file, Ifyou found can you check any referraltin the hospital claim? paella fee elfen James: That's okay Sandy, May have the PCP name (Primary Care Physician) and his phone number? Sandy: James the PCP name is Mark Taylor and his Phonet is 1800-586-93; James: Thanks Sandy and what is the corrected claim mailing address anc corrected claim? Sandy: Ye ite PO BOX 74088 ATLANTA GA 30378 and TFL i 120, James: Thank you so much Sandy and what is the claim#?- Sandy: The claim is UASS823 James: And what i the cal referenced? ‘Sandy: The call reference# is my name and today’s date James: Thank you so much Sandy you are very hell ‘Sandy: Thanks James its a pleasure talking to bye.. bye ely filing limit for the 9.sandy:Clal James: May | know what pla Sandy: The patient Jarnes: Could you Sandy: The call referenced is my name and today's date James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you end you have a good day. bye.. bye. EEE YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,11. James: Thank you so much for holding | appreciate your patience! “Sandy, | cannot find any referral in my system so do you see any referral or file? Sandy: No James James: Sandy can you please check any hospital claim on file, If you found can you check any referralttin the hospital claim? Sandy: James | checked and | cannot find any hospital claim on this DOS: James: That's okay Sandy, May | have the PCP name (Primary Care Physician) and his phone number? Sandy: James the PCP name is Mark Taylor and his Phone# is 1800-586-9321. James: Thanks Sandy and what is the corrected claim mailing address and timely filing limit for the corrected claim? Sandy: Yes, it is PO BOX 74088 ATLANTA GA 30374 and TFL is 120 days from the denied date. James: Thank you so much Sandy and what is the claim#? Sandy: The claim# is UASS823 James: And what is the call reference? Sandy: The call referenced is my name and today's date James: Thank you so much Sandy you are very helpful to me today and youhave a nice Sandy: Thanks James it’s a pleasure talking to you and yohave @good bye. bye.. 4Sandy: Thanks for calling this is Sandy, haw may |help you? James: Hi, my name is James, | am calling for Doctor's office and | would like to check the claim. status for a patient Sandy: Which Doctor's office you calling for? James: | am calling for General Orthopedic associates YTV iLLINGS WEB-VBCEREER.COM INSTA/FB=VBCAREER,Sandy: What is your telephone number? James: My telephonet is 800-999.9999 Sandy: What is the patient's SSN (social security number)? James: The SSN is 123-456-789 Sandy: Could you please hold for a moment so that I can pull the patient records? James: Yes, please! Sandy: What is the patient's name and DOB? 2.James: The patient name is Linda Far and DOB is 11-26-1995 Sandy: What is the DOS you checking for? James: The DOS is 04-02-2020 Sandy: What is the billed amount on this claim? James: The billed amount is $1500.00 Sandy: Could you please hold for a moment so that | can pull up thaeaim: James: Yes Of cour: ‘Sandy: Thanks for being on hold James, the claim was denied? James: Okay may | know the claim received date? Sandy: The claim was received on 04-18-2020 3.James: And what is the denial date? Sandy: The denial date is 04-22-2020 James: May | know the reason for the denial? Sandy: Let me check James James: Okay 4Sandy: James Sandy: So far ut and also no response for both letters ond letter cont out date? Sandy: Okay can ase hold so that | make a note to initiate to send 3rd letter? James: Yeah take your own time! ‘Sandy: Thanks for being on hold James, the 3rd letter has been send out today and this is the final letter that we can send. lames: Thanks Sandy could you please tell me how the patient could update the COR? Sandy: James patient can call the benefits department in-order to update the COB James: So what is the benefits department phone number? Sandy: Yes, itis 877-852-4230 5.James: Thanks Sandy, Is there any time frame for the patient to update it? Sandy: There is no time frame, but make the patient update it as soon as possible YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,James: Sure Sandy, could you please tell me when did the patient last updated the cob? Sandy: The COB was last updated on 02-08-2019 James: Okay Sandy can we bill he patient for this claim? Sandy: Yes you can bill the patient James: Could you please send me the eob through our faxtt Sandy: Okay what is your faxtt James: Yes itis 1877-333-4567 and you can put the attention as my name James Sandy: Okay fax request has been initiated and it will receive within 24 hours James: Thank you so much Sandy and what is the claim#? Sandy: The claim# is XYZ5823, James: And what is the call reference? Sandy: The call referenced is my name and today’s date James: Thank you so much Sandy you are very helpful to me today and vé Sandy: Thanks James its a pleasure talking to you and you have a bye.. bye.. day! Sandy: Let me check James James: Okay Sandy: James we have sent out: James: Did you received ar Sandy: Let me check James James: Okay call reference? is my name and today's date James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye. ‘9.James: Okay Sandy could you please hold for a moment | check more information on this claim Sandy: Okay | will be waiting for 2 minutes YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,James: Okay, thanks for being on hold, | checked the billing summary and found a claim for the DOS 05-08-2020 has been paid can you please check hew it was paid? Sandy: let me check James James: Okay Sandy: James this claim has been paid also the cob never updated | don't know how it was paid James: Yes Sandy but we have received payment s9 can you please send this claim to reprocess with reference to the paid one Sandy: Okay can you please hold so that I make a note and send this claim for reprocessing James: Yeah take your own time! James: Okay Sandy take your own time Sandy: James thanks for being on hold, | sent this claim back for reprocessing, and please be allow 45 business for review. James: Thank you so much Sandy and what is the claim#? Sandy: The claimt is X¥Z5823, James: And what is the call reference#? Sandy: The call reference# is my name and today’s date James: Thank you so much Sandy you are very helpful to, Sandy: Thanks James its a pleasure talking to you end you bye.. bye.. James: Hi, my name is James, | am calling status for a patient 2uJames: The p sme is Linda Far and DOB is 11-26-1995 Sandy: What is the DOS\you checking for? James: The DOS is 04-02-2020 Sandy: What is the billed amount on this claim? James: The billed amount is $1500.00 Sandy; Could you please hold for a moment so that can pull up the claim? James: Yes Of course! Sandy: Thanks for being on hold James, the claim was denied? James: Okay may | know the claim received date? Sandy: The claim was received on 04-18-2020 YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,a7 3uames: And what is the denial date? Sandy: The denial date is 04-22-2020 James: May | know the reason for the denial? Sandy: Claim was denied for the patient is not active on the DOS James: May | know the patient policy effective anc termed date? Sandy: Yes the policy has been effective from 02-22-2019 to 02-21-2020 James: Okay Sandy could you please check that this patient has any other active policy on this DOS? Sandy: James patient doesn't have any other active policy 4.James: Okay Sandy can we bill the patient for this claim? Sandy: Yes you can bill the patient James: Could you please send me the eob through our faxtt, Sandy: Okay what is your fax James: Ves itis 1877-333-1567 and you can put the attention as yea Sandy: Okay fax request has been initiated and it will receive within 24 hours James: Thank you so much Sandy and what is the claim#? Sandy: The claimé is XYN5823 James: And what is the call reference? Sandy: The call referencet is my name and today's James: Thank you so much Sandy you are ver Sandy: Thanks James it’s a pleasure talking to v you have a nice day! 6.James: Okay Sandy could Sandy: Okay | will be Jarnes: Okay, Ul I check more information on this claim y aud found a 1 fur the DOS d also the patient policy has been renewed recently on 04-01- back for repiocess and can you please hold sv that | make @ jaim for reprocessing James: Okay Sandy take your own time Sandy: James thanks for being on hold, | sent this claim back for reprocessing, and please be allow 30 business for review. James: Thank you so much Sandy and what is the claim#?, Sandy: The claimtt is XYNS823, James: And what is the call reference#? Sandy: The call referenced is my name and today’s date James: Thank you so much Sandy you are very helpful to me today and you have a nice day! Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye.. YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,‘8.James: Okay Sandy could you please check that this patient has any other active policy on this. pos? Sandy: Let me check James James: Okay Sandy take your own time Sandy: James thanks for being on hold, | found patient has anew active policy on this DOS James: Okay Sandy can you please provide me the new policy number? Sandy: Vee Jamee the new policyit ic 12345678 James: May | know the new policy effective and termed date? Sandy: Yes the policy has been effective from 02-21-2020 and there is no. James: So can you please send this claim to reprocess under this new pol Sandy: James | cannot send it back, since this is a new policy so the provi submit it James: Okay and what is the mailing address and timely filing li ‘new policy? Sandy: Of course, itis PO BOX 80669 SALT LAKE CITY UT 84230 ad time James: Thank you so much Sandy and what is the claim Sandy: The claim# is XYN5823 James: And what is the call reference? Sandy: The call referenced is my name and tos James: Okay Sandy: James the phone number is 213-456-7896 James: Could you please send me the eob through our faxtt, Sandy: Okay what is your fen James: Yes itis 1877-333-4567 and you can put the attention as my name James Sandy: Okay fax request has been initiated and it will receive within 24 hours James: Thank you so much Sandy and what is the claim#? Sandy: The claimt is XYN5823 James: And what is the call reference#? Sandy: The call referenced is my name and today’s date YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,James: Thank you so much Sandy you are very helpful to me today and you have @ nice day! Sandy: Thanks James its a pleasure talking to you end you have a good day. bye.. bye.. 1.Sandy: Thanks for calling James: Hi, my name i uF ice and | would like to check the claim Sandy: Coul hold for a moment so that I can pull the patient records? James: Yes, pleas Sandy: What is the patient's name and DOB? 2.James: The patient name is Linda Far and DOB is 11-26-1995 Sandy: What is the DOS you checking tor? James: The DOS is 04-02-2020 Sandy: What is the billed amount on this claim? James: The billed amount is $1500.00 Sandy: Could you please hold for a moment so that I can pull up the claim? James: Yes Of course! YTV iLLINGS WEB-VBCEREER.COM INSTA/FB-VBCAREER,8 4.Sandy: Thanks for being on hold James, the claim was denied? James: Okay may | know the claim received date? Sandy: The claim was received on 04-10-2020 James: And what is the denial date? Sandy: The denial date is 04-20-2020 Jamec: May I know the reacon for the denial? Sandy: Claim was denied as Duplicate James: Could you please check this claim was received as corrected claim claim? Sandy: The claim was received as a new claim without any corrections James: May | know the original claim status? Sandy: The original claim was paid James: What isthe original claim received date? Sandy: James the original claim was received on 04-07-2020 James: What is the original claim paid date? 5.Sandy: The original claim was paid on 04-17-2020 James: May | get the paid formation? Sandy: It was paid for 800.00 with patient respon here I have cut down the paid scenari ***Please use complete paid (if original fention as my name James receive within 24 hours, te claim XYBS678? jou ate very helpful to me touay end you have @ its a pleasure talking to you end you have a good day. jee day! 7.Sandy: Claim was denied as Duplicate James: Could you please check this claim was received as a corrected claim or anew claim? Sandy: The claim was received as a new claim without any corrections James: Could you please hold for a moment so that | can check both claims Sandy: Okay | wil be waiting for 2 minutes only James: okay...Thanks for being on hold Sandy, upon checking I found The primary Diagnosis code we YEeve.uines Wen-vaceneeR.com INSTA/FB=VBCAREER,