Embedded Files
CLAIM PAID TO PROVIDER
Claim Paid
↓
What is the processed & paid date?
↓
What are the allowed amount, paid amount and
patient responsibility (Coins, Deductible or Co-payment)?
↓
Verify sum of PA and Patient Responsibility(PTR) equals to AA,
if not then probe the rep and get the correct information
Click here to validate payment information
↓
Was payment done through Check or EFT/Credit Card?
↙ ↘
Check EFT/Credit Card
↓ ↓
What is the check#? What is the Transaction ID?
↓ ↓
Was it Single check or Bulk check#? Was it single payment or Bulk payment?
↙ ↘ ↙ ↘
Single check Bulk Check Single payment Bulk payment
↘ ↓ ↘ ↓
↘ What is the Bulk Amount? ↘ What is the Bulk Payment Amount?
↘ ↙ ↘ ↙
May I have the check mailing address? Is payment cleared?
↓ ↙ ↓ ↘
Validate address provided by rep with Yes Not Provided No
the address available in box# 32 and 33 ↓ ↓ ↓
↙ ↘ ↓ ↓ ↓
Correct Incorrect ↓ ↓ ↓
↓ ↘ May I have the ↓ EFT/Credit card
Is the check cashed? ↘ encashment date ↓ payment takes 2-3
↙ ↘ ↘ → → → ↘ ↓ ↙ days for clearance
Yes No ↘ Provide correct Could you please but not more than
↓ ↓ Rep does not check mailing fax the EOB? If 7 days. So, if the paid
May I have the ↓ have encashment address to rep & not then mail it or date has crossed 7 days
encashment ↓ date information? ask to reissue new provide the source then it means payment
date? ↓ ↓ check to get the EOB might get cancelled. So,
↓ ↓ Could you please ↓ ↘ verify same with rep &
Could you please Is paid date fax the EOB? If rep agrees? May I have ask rep to reissue new
fax the EOB? If crossed 45 days? not then mail it ↙ ↘ the Claim# & payment
Not then mail it ↙ ↘ or provide the source Yes No Call ref ↓
or provide the ↙ ↘ to get the EOB ↓ ↘ rep agrees?
source to get the ↙ ↘ ↘ What is the TAT? What is the ↙ ↘
EOB Yes No ↘ ↓ reason? Yes No
↓ ↓ ↘ → May I have ↓ ↓ ↓
May I have the Could you please How many days the claim# & Can I get the fax# What is What is the
claim# & Call run check tracker will it take to Call ref#? or mailing address TAT? reason?
ref#? to get the current clear the check? to send W9 form ↓ ↓
status of the check? ↓ to update the correct ↓ Could you
↓ Could you please address? May I have please fax the
Rep agrees fax the EOB? If ↓ the Claim# & the EOB? If
↙ ↘ not then mail it May I have the Call ref#? not then mail
Yes No or provide the source Claim# & Call ref#? it or provide
↓ ↓ to get the EOB the source to
What is the TAT? ↓ ↓ the EOB
↓ ↓ May I have the ↓
Could you please fax the EOB? Claim# & Call ref#? May I have
If not then mail it or provide the the claim# &
source to get the EOB call ref#?
↓
May I have the Claim#
& Call ref#?
CLAIM PAID TO PATIENT PATIENT
Claim Paid to Patient
↓
What is the processed & paid date?
↓
What are the allowed amount, paid amount and
patient responsibility (Coins, Deductible or Co-payment)?
↓
Verify sum of PA and Patient Responsibility(PTR) equals to AA,
if not then probe the rep and get the correct information
Click here to validate payment information
↓
Why was the claim paid to patient?
↓
May I have the claim# & call ref#
DEDUCTIBLE
Claim applied toward Deductible
↓
May I have the processed date?
↓
What is the Allowed Amount(AA)?
↓
How much is the total deductible limit on the policy?
↓
How much has patient met including this claim?
↙ ↘
If patient has met the deductible including this claim/ If patient has already met the
Patient has not met the deductible including this claim deductible excluding this claim
↓ ↓
Could you please fax the EOB? If not then mail it Could you please send the claim
or provide the source to get the EOB? back for reprocessing since
↓ patient has already met his
May I have the claim# & call ref#? deductible excluding this claim?
↓
What is the Turn around
time(TAT) for reprocessing?
↓
May I have the claim# & call ref#?
CLAIM IN PROGRESS
Claim in process
↓
When did you receive the claim?
↓
What is the normal processing
time or TAT?
↓
Calculate TAT from received
date and check if is it within the TAT?
↙ ↘
Yes No
↓ ↓
May I get Claim# May I have the
& Call ref#? reason for delay?
↙ ↓ ↘ ⟶ ⟶ ⟶
↙ ↓ ↓
Any Information Information requested Other Reasons
or documents from patient (Backlog)
requested from ↓ ↓
provider Have you sent May I get
↓ letter to patient? Claim# &
What documents/info ↙ ↘ Call ref#?
requested? Yes No
↓ ↓ ↓
May I have the When did May I get
address or Fax# to you send Claim# &
send the document/info? the letter? Call ref#?
↓ ↓
May I get Claim# May I get
& Call ref#? Claim# &
Call ref#?
NO CLAIM ON FILE
No claim on file
↓
May I have policy effective and termed date?
↓
Check DOS lies between effective and termed date
↙ ↘
Yes No
↓ ↓
May I have the TFL? ← ← Is there any other policy
↓ ↖ active for the patient on DOS?
Check DOS lies within TFL ↖ ↙ ↘
↙ ↘ ↖ Yes No
Yes No ↖ ↓ ↓
↓ ↓ ← May I have May I get
May I have claim Can we fax or Policy ID, Policy call ref#?
mailing address, mail the claim effective and
Payer ID and Fax#? along with POTF? termed Date?
↓ ↖ ↙ ↘
May I get call ref#? ↖ ← No Yes
↓
May I have Fax#
or Mailing address
to send claim along
with POTF?
↓
May I get call ref#?
CANNOT ID PATIENT
Patient cannot be identified
↓
Could you please search the patient with
Name, DOB or Social Security#?
↙ ↘
If rep finds the patient If rep unable to find patient
↓ ↓
May I have the correct policy ID? May I get call ref#?
↓
Could you please check if claim
is available for the DOS with correct
member ID?
↙ ↘
Yes No
↓ ↘
Follow AR Scenario May I have the effective and
Tool as per the claim status termed date of the policy?
Check if DOS lies between
effective and termed date
↙ ↘
No Yes
↓ ↓
May I get call ref#? May I have the Timely
filing limit(TFL)?
↓
Check DOS lies within TFL
↙ ↘
Yes No
↙ ↓
May I have claim Can we fax or mail the
mailing address, ← claim along with POTF?
Payer ID and Fax#? ↖ ↙ ↘
↓ ← No Yes
May I get call ref#? ↓
May I have Fax#
or Mailing address
to send claim along
with POTF?
↓
May I get call ref#?
OTHER INS PRIMARY
Claim denied as other payer is primary
↓
May I get the denial date?
↓
Could you please tell me which
insurance is the primary insurance?
↓
Does rep have the details?
↙ ↘
Yes No
↙ ↘
What is the effective & May I have the claim#
termed date of the policy? & call ref#?
↙ ↘
Rep have the details Rep does not have details
↓ ↘
Was policy active on DOS? What is the policy id, payer id
↙ ↘ & mailing address of primary
Yes No insurance?
↓ ↓ ↓
What is the Could you please May I have the
policy id, payer id reprocess the claim claim# & call ref#?
& mailing address since there is no active
of primary primary insurance?
insurance? ↓
↓ ↙ What is the TAT?
May I have the ↙
claim# & call ref#?
NO COVERAGE ON DOS
Claim denied as This provider was not certified/eligible to be paid for thisprocedure/service on this DOS
↓
May I get the denial date?
↓
What is the exact issue?
↙ ↓ ↘
The rendering provider The referring provider The procedure code is inconsistent
is not eligible to perform is not eligible to refer with the provider type/specialty
the service billed the service billed or taxonomy code is invalid
↓ ↓ ↓
CODING DENIAL
Claim denied as diagnosis code is
inconsistent with the procedure
↓
May I get the denial date?
↓
Could you please tell me which diagnosis code
is inconsistent (If there are multiple DX code coded)?
↓
Check patient payment history if the same
DX code paid with same CPT
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as What is the time limit to
payment received for same CPT & DX? send corrected claim?
↓ ↓
What is the TAT for reprocessing? What is the Fax# or Mailing
↓ address to send an appeal?
May I have the claim# & call ref#? ↓
How much is the time limit
to send an appeal?
↓
May I have the claim# & call ref#?
INCLUSIVE
Claim denied as Bundle/Inclusive
↓
May I get the denial date?
↓
To which CPT is it bundled with?
↓
What is the time limit to send corrected claim?
↓
What is the fax# or mailing address to send an appeal?
↓
May I have the claim# and Call ref#?
NOT MEDICALLY NECESSARY
Claim denied as medically not necessity
↓
May I get the denial date?
↓
What is the reason for medically not necessity?
↓
Check patient payment history if the same
DX code paid with same CPT
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as What is the time limit to What is the Fax# or Mailing
payment received for same CPT & DX? send corrected claim? → address to send an appeal?
↓ ↓
What is the TAT for reprocessing? → May I have the ← How much is the time limit
claim# & call ref#? to send an appeal?
ADDITONAL INFORMATION
Claim denied as additional information requested from provider
↓
May I get the denial date?
↓
What kind of documents have you
requested from provider?
↓
What is the Fax# or Mailing address
to send the document?
↓
How much is the time limit to send the document?
↓
May I have the claim# & call ref#?
Claim denied/pending as additional information requested from patient
↓
When did you receive this claim?
↓
May I get the denial date?
(If claim is denied)
↓
What information have you requested from patient?
↙ ↘
Patient needs to update COB information Other Reasons
↓ ↓
Have you sent letter to patient? Have you sent letter to patient?
↙ ↘ ↙ ↘
Yes No Yes No
↓ ↓ ↓ ↓
When did you When did patient last When did you May I get the
sent the letter? update the COB sent the letter? claim# and Call ref#?
↓ information? ↓
Have you received ↓ Have you received
any response from May I get the any response from
patient? claim# and Call ref#? patient?
↙ ↘ ↙ ↘
Yes No Yes No
↓ ↘ ↓ ↘
Could you When did patient Could you May I get the
please reprocess last update the please reprocess claim# and Call ref#?
the claim? COB information? the claim?
↓ ↓ ↓
What is the TAT May I get the What is the TAT
for reprocessing? claim# and Call ref#? for reprocessing?
↓ ↓
May I get the May I get the
claim# and Call claim# and Call
ref#? ref#?
AUTHORIZATION
Claim denied as Authorization
Absent or Missing
↓
May I get the denial date?
↓
Check in system if Auth# is Available
↙ ↘
Yes No
↓ ↓
I have the Auth#, Can you please Check place of service billed on
reprocess the claim using this Auth#? claim is 23 (Emergency) or not
↓ ↗ ↙ ↘
Rep Agrees? ↗ Yes No
↙ ↓ ↗ ↓ ↓
Yes No ↗ ↓ Do you have Auth# on file? OR
↙ ↙ ↘ ↑ Could you please Is there any hospital claim
What is turn Need to Auth# is reprocess the claim billed on same DOS where
around time send an invalid since it is an authorization# present?
for processing? corrected emergency service (The above highlighted question
↓ claim & does not require is only applicable for
May I have the ↓ Auth#? non-hospital billing claims)
claim# & call ref#? What is ↓ ↗ ↙ ↘
the time Rep Agrees? ↗ Yes No
limit to send ↙ ↘ ↗ ↓ ↓
a corrected Yes No ↓ ↓
claim? ↓ Could you please Is it possible to
↓ What is the TAT ← ← use that Auth# and obtain Retro
May I have the for reprocessing? send claim back for Authorization#?
claim# & call ref#? ↓ reprocessing? ↙ ↘
May I have the Yes No
claim# & call ref#? ↙ ↓
What is the What is the
procedure to obtain Fax# or mailing
retro Auth#? address to send
↓ an appeal?
May I have the ↓
claim# & call How much is
ref#? the time limit?
↓
May I have the
claim# & call
ref#?
MISSING/INVALID REFERRAL
Claim denied as referral is absent or missing
↓
May I get the denial date?
↓
What plan does patient has? (HMO, PPO, EPO, POS)
↙ ↙ ↘ ↘
↙ ↙ ↘ ↘
HMO POS PPO EPO
↘ ↙ ↘ ↙
↘ ↙ ↘ ↙
Check in system if Could you please send claim
referral# is available back for reprocessing since
↙ ↘ patient plan does not require
Yes No referral#?
↙ ↓ ↓
I have the referral#, can Do you have referral# on file? What is the turn around
you please reprocess OR Is there any hospital claim time?
the claim using it? billed on same DOS where ↓
↓ referral# present? May I have the claim#
What is the turn around (The above highlighted question & call ref#?
time? is only applicable for
↓ non-hospital billing claims)
May I have the claim# ↙ ↘
& call ref#? Yes No
↓ ↓
Could you please use What is the Fax# or
same referral# & send mailing address to
claim back for send an appeal?
reprocessing? ↓
↓ How much is the time
What is the turn around limit?
time? ↓
↓ May I have the claim#
May I have the claim# & call ref#?
& call ref#?
MAXIMUM BENEFIT MET
Claim denied as patient has reached the maximum benefit allowed
↓
May I get the denial date?
↓
May I know maximum benefit reached in terms of dollar or visit?
↙ ↘
In terms of Dollar In terms of Visit
↓ ↓
How much Dollar amount How many Visit is
is allowed? allowed?
↓ ↓
How much dollar amount has How much visit has patient
patient met excluding this claim? met excluding this claim?
↓ ↓
Has patient met the allowed dollar Has patient met the allowed visit
amount excluding this claim? excluding this claim?
↙ ↘ ↙ ↘
Yes No Yes No
↓ ↓ ↓ ↓
May I have the Could you please May I have the Could you please
claim# & call ref#? send the claim back claim# & call ref#? send the claim back
for reprocessing since for reprocessing since
patient has not met the patient has not met the
the allowed dollar allowed visits
amount excluding this amount excluding this
claim? claim?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
↓ ↓
May I have the May I have the
claim# & call ref#? claim# & call ref#?
DUPLICATE
Claim denied as duplicate
↓
May I get the denial date?
↓
Check if CPT of your charge billed
more than once on same DOS
↙ ↘
No Yes
↙ ↓
What is the original Check if modifier, rendering provider
status of the claim? and exam time on medical records are same
↓ ↙ ↘
Follow AR scenario tool No Yes
for original claim status ↓ ↓
Click Here Can you please reprocess May I have the
the claim since modifier, claim# & call ref#?
rendering provider or exam time
on medical records are different?
↓
Rep Agrees?
↙ ↘
Yes No
↙ ↙ ↘
What is the TAT Rep asked to Rep asked to
for reprocessing? send corrected submit an appeal
↓ claim ↓
May I have the ↓ What is the Fax# or
claim# & call ref#? What is the Mailing address to
time frame for send an appeal?
corrected claim? ↓
↓ How much is the
May I have the time limit?
Claim# & Call ref#? ↓
May I have the
Claim# & Call ref#?
PAST TIMELY FILING LIMIT
Claim denied as Past timely
filing or TFL expired
↓
May I get the denial date?
↓
When did you receive the claim?
↓
How much is the Timely filing limit?
↓
Check if the claim was received within TFL
↙ ↘
Yes No
↓ ↓
Could you please send the Check if POTF available
claim back for reprocessing ↙ ↘
since the claim was received Yes No
within TFL? ↓ ↓
↓ Can we appeal with POTF? May I have
What is the TAT for reprocessing? ↓ the claim# &
↓ What is the fax# or Mailing call ref#?
May I have the claim# & address to send an appeal? &
call ref#? What is the appeal limit?
↓
May I have the claim# &
call ref#?
NON COVERED SERVICES
Claim denied as Non Covered Charges
↓
May I get the denial date?
↓
Is it non covered as per patient plan or provider contract ?
↙ ↘
Non covered as per patient plan Non covered as per provider contract
↓ ↓
What is the reason for non covered? What is the reason for non covered?
↙ ↓ ↘ ↙ ↘
Provider is DX or ICD-10 other CPT non covered under Other reasons
out of network non covered reasons provider contract ↓
↓ ↓ ↓ ↓ Follow AR
Click Here What is the May I Check payment history Scenario Tool
time frame to have the if payment received for same Click Here
submit the claim# & CPT with same provider from
corrected claim? call ref#? same insurance
↓ ↙ ↘
May I have the Yes No
Claim# & Call ↓ ↓
ref#? Could you please send claim What is fax# or Appeal
back for reprocessing since address to send the appeal?
we have received payment for ↓
same procedure? How much is the appeal limit?
↓ ↓
Rep Agrees? May I have the
↙ ↘ claim# & call ref#?
Yes No
↙ ↘
What is the TAT What is fax# or Appeal
for reprocessing? address to send the appeal?
↓ ↓
May I have the How much is the appeal limit?
claim# & call ref#? ↓
May I have the
claim# & call ref#?
Claim denied as non covered services as per patient plan as provider is out of network
↓
May I get the denial date?
↓
Does patient plan cover out of network benefit?
↓
What plan does patient has? (HMO, PPO, EPO, POS)
↙ ↙ ↘ ↘
↙ ↙ ↘ ↘
HMO PPO EPO POS
↙ ↓ ↓ ↘
May I have the Could you please May I have the Could you please
claim# & call ref#? reprocess the claim claim# & call ref#? reprocess the claim
since patient plan since patient plan
does cover out of does cover out of
network benefit? network benefit?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
↓ ↓
May I have the May I have the
claim# & call ref#? claim# & call ref#?
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