GBSS: Accounts Receivable, Follow-up Quick Reference Guide

Applies to: All Stakeholder(s): New Onboards

Section C: Top Ten Denials

Chapter 1: Overview of Denial Management

Level 3 C. Top Ten Denials 1. Overview of Denial Management

1.1 What is Claim Resolution?

A typical day of an AR Executive starts when
he gets an inventory of claims assigned. While
processing a claim, the objective is to provide
Claim Resolution. The goal is to achieve
Production targets by resolving claim and
meeting Quality standards by providing
accurate resolution.

Claim Resolution can be provided when we Insurance Company Patient

are able to recover the billed amount from
Insurance Company or Patient.

1.2 CLAIM ANALYSIS

There are three sequential steps to be followed while analyzing a Claim:

Pre-Call Analysis On-Call Analysis Claim Resolution

1.2.1 IMPORTANCE OF PRE-CALL ANALYSIS

All claims do not require calling. Using resources at our disposal as well as performing a thorough pre-call analysis helps to…

Identify key denial Reduce Follow-up time Eliminate Errors Prevent Further Denials
reason

© R1 RCM Inc. | Global Technical Learning | Confidential and Proprietary | Last Revision – October 2020 | Page 1 of 3
GBSS: Accounts Receivable, Follow-up Quick Reference Guide
Applies to: All Stakeholder(s): New Onboards

1.2.2 PRE-CALL ANALYSIS RESOURCES

Resources Definition

A Client System also referred to as

the Host system contains Claim
Client System billing information, Patient details,
insurance information, as well as EOB
explaining any Denials or Payments
on a claim

ANTHONY, JOHN
XJWH0000000
Aug 12 1984

2100 Rock Valley RD 0000000

OVIEDO, FL 30000
XJWH0000000

Patient policy effective

and termed date
Insurance websites are used to check
Insurance and verify Patient's Eligibility and,
Website Coordination of Benefit details.
COB

John Anthony
12345678A

ANTHONY, JOHN
XJWH0000000

Standard Operating Procedure or SOP

Standard
is a client specific document. It
Operating
provides guidelines to be followed
Procedure
while processing a claim.

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GBSS: Accounts Receivable, Follow-up Quick Reference Guide
Applies to: All Stakeholder(s): New Onboards

1.2.3 ON CALL ANALYSIS

Here is a Ready Reckoner of mandatory questions, for performing On-call Analysis.

• Ask for Insurance Representative’s Name

• Verify Claim Number, Claim Received and Processed Date
• Confirm Denial Date and Reason for Denial
• Check for Additional Documents required
• Check Claim Processing Time and if any Additional
Documents are required
• Take Claims Mailing Address (for billing/re-billing) On-Call Analysis
• Understand Bill Submission Process
• Take concerned Department’s/Individual’s details
• Note the Call Reference Number

1.2.4 CLAIM RESOLUTION

Claim Resolution involves documenting all our findings and tasking appropriately, based on the Pre-call
or On-call analysis. Detailed documentation and tasking should be done on the Client system to
eliminate errors.

For example- if a claim needs to be billed to the patient, then it should be tasked to the Billing team.

1.2.5 TIPS & TRICKS

Tasked to Billing

Quick Tips
Pre-Call Analysis
Perform a thorough pre-call analysis to reduce
follow-up time and to determine whether a call is
required to provide claim resolution

On-Call Analysis
Prob on call to obtain all the details. Keep pre-call
analysis findings and notes ready before making a call
to Insurance to reduce on-call time.

Claim Resolution
Document all the details and task the claim
appropriately to eliminate errors.

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