AR Trainings - Basic Questions A To Z

\AR CONTENT TRAINING:
1. Denial management.
1.1 . Types of denial.
1.2 . Denial case studies.
2. Client specific training.
3. Conducting test.
4. Barging and mock calling.
1. Denial management.
1.1 Types of denial:
1.1.1 Claim paid.
1.1.2 Claim denied for untimely filing.
Claim would be denied for this reason when filed after the filing limit or
the carrier receives after the limit.
1.1.3 Claim denied as duplicate.
There are two types of duplicate denial.
a. Duplicate submission
Claim would be denied for duplicate submission when two
similar claims filed for the same date of service for the same
provider for the same procedure and for the same diagnosis. Claim
could be denied for this reason even if filed with different
diagnosis or with different doctor.
b. Duplicate charge
Claim would be denied as duplicate charge when two
similar codes filed on the same claim.
1.1.4 Claim denied as incidental or inclusive.
When the carrier considers a procedure code to be inclusive to the
primary procedure performed then it is said to be inclusive. Procedures that are
considered incidental when billed with related primary procedures on the same date
of service will be denied.
1.1.5 Claim denied as bundled.
When the procedures performed are bundled together to pay under a
new procedure is called bundled (In this the charges of the bundled codes will also
be bundled to have the entire billed amount).
1.1.6 Claim denied as global.
The pre-operative and post-operative procedures are considered to be
global. Global procedures will never get paid. A defined period of time (0 to 90
days) during which all-medical services related to a similar condition or diagnosis
are included in the payment for the initial surgery.
1.1.7 Claim is in process.
When the claim pended for review after receiving it, then it is states
claim in process.
1.1.8 Claim denied for the need of Pre-existing review information or Pre-existing
condition.
When a diagnosis code is considered to be related to the pre-existing
condition determined, payer would request for medical records from the doctor and
also from the patients other physicians for the a certain diagnosed period to
determine the condition. If these requests were not responded by the any of the
physician, then the claim would be denied for the need of pre-existing review
information.
When this information reviewed by the payer concludes that the filed
diagnosis is related to pre-existing benefits then it would be denied as pre-existing
condition.
1.1.9 Claim denied as medicare denied.
When medicare process the claim as primary and denied with no
payment, then the secondary carrier would deny it as medicare denied if they are
under medicare supplemental plan.
1.1.10 Claim denied as not medically necessary.
When the payer determines that the service provided pertaining to the
diagnosis is not necessary in this service condition then it would be denied as not
medically necessary.
1.1.11 Claim denied as patient not eligible.
If the patient was terminated before the date of service or eligible only
after the date of service, or dependent not yet included in the policy, then the claim
would be denied as patient not eligible.
1.1.12 Claim applied towards deductibles.
If the patient has not met the yearly deductibles amount or the provider
not participating with that carrier (when the patient has out of network deductibles),
then the claim would be applied towards patient’s deductibles.
1.1.13 Claim applied towards out of pocket expenses.
If the patient has not met the yearly out of pocket expenses (e.g.
coinsurance, co-pay) or the patient has carved out plan (when primary is medicare)
then the amount would be applied towards coinsurance.
1.1.14 Claim denied for the need of primary eob.
Claim would be denied for this reason if they do not receive the
primary explanation of benefits along with the secondary claim filed.
1.1.15 Claim denied for prior authorization.
When the claim is received with no authorization # mentioned on the
claim form or no authorization obtained (often in the case when the payer
determines that this service should have been authorized) for the service billed, then
it would be denied for this reason.
1.1.16 Claim denied for referral.
When the claim is received with no referral in the case of HMO plan
then the claim would be denied for the need of referral authorization.
1.1.17 Claim denied for PCP information.
If the patient has not selected the PCP in the case of HMO plan when
the benefits issued, then the claim would denied requesting the PCP information.
1.1.18 Claim denied for provider information. (Tax id, individual provider id #,
group information)
When the claim billed lacks any of the above said provider details then
the claim would be denied for tax id # or for incorrect provider id # or for incorrect
address or for the need of W-9 form.
1.1.19 Claim denied for Coordination of benefits information.
If the patient has not updated the yearly COB questionnaire or never
recorded that information with the carrier or for the lack of lack of this information,
payer would deny for this reason
1.1.20 Claim denied as mutually exclusive.
Mutually exclusive codes are those codes that cannot reasonably be
done in the same session. In this case the same procedure would have been done
using two different methods. If both codes accomplish the same result, the clinically
more intense procedure survives and the comparative code would be denied as
mutually exclusive.
1.1.21 Claim denied for information pertaining to patient. (Signature missing, BIC,
new group or id #, full time student status)
Claims that lack patient’s information would be denied for this reason.
1.1.22 Claim denied as not covered services.
When a service performed is not included as payable in the patient’s
benefits, then the claim would be denied as not covered services.
1.1.23 Claim purged.
Some insurance companies would hold the information in their
system only for a certain period from the date of processing due to their data storage
limitation. In this case, we will not get any information from the rep and it is
considered as purged.
1.1.24 Claim denied for employer information.
Claim would be denied for this reason if the patient has not submitted
the employer information.
1.1.25 Claim denied for place of service.
Claim would be denied for invalid place of service used when there is
a discrepancy on the CPT code and pos billed. For ex: CPT code would be related to
inpatient service whereas the pos service indicated was for outpatient observation
service.
1.1.26 Claim denied for incorrect diagnosis code.
Claim would be denied for this reason if the number of digits in the
code missing or irrelevant to the earlier diagnoses.
1.1.27 Claim denied for incorrect procedure code.
If the procedure performed is not related to the diagnosis or the
procedure code is not listed in their state CPT manual then the claim would be
denied as invalid CPT code.
1.1.28 Claim not on file.
When they do not have any information regarding the date the service
queried then it is considered not on file.
1.1.29 Claim denied for incorrect modifier.
If the modifier used is irrelevant to the CPT code billed or no
modifier used in the case of necessity, then the claim would be denied for this
reason.
1.1.30 Claim denied as non-participating provider.
If the provider not participating in a particular plan or not in the
network then the claim would be denied as non-par or out of network.
1.1.31 Claim processed towards capitation.
If the provider is contracted with the insurance company to receive
payment in the monthly or contracted basis then it would be processed towards
capitation.
1.1.32. Claim paid to patient.
If the claim processed out of network or if the patient has not signed
the assignment of benefits then the claim would be paid to the patient.
1.2 Denial Case studies.

(Assumed) Ex: Patients name: Kim carter
DOB: 05/17/80
Patient’s id #: YRM28097528
DOS: 04/02/04
Billed amount: $76
Procedure code: 99213
Diagnosis code: V202
Tax id #: 510729852
Provider name: Steven Cutler
Provider’s address: po box-600728, Austin, Tx-77339.
Insurance carrier: Blue cross and Blue shield of Texas
1.2.1 Claim paid.

1. When was the claim paid and ask for the check date?
Claim paid on 04/24/04.
2. What is the amount paid?
Paid $35
3. What is the check #?
Check # is 001608527.
4. May I have the allowed amount of this claim?
Allowed amount is $50.
5. Does the patient have any responsibility? If yes, was
that applied towards coinsurance or co-pay or
deductibles?
Patient has $10 as copay and $5 as
deductibles.
6. Was the check cashed?
Check was cashed on 05/02/04.
7. What is the total (bulk) amount of the check?
It’s a single check.
8. May I verify the address where the check was sent?
Check was sent the address mentioned box
33 of the hcfa form
9. May I have the claim #?
Claim # is 04258fe234f00.
If the check was not cashed, request for check tracer and when cashed request for copy
of the cancelled check if not received. Also request for copy of an explanation of benefits to be mailed or
faxed.
Issue code to be selected:
Notes to be entered:
Called blue cross and blue shield of Texas at 800-451-0287 and spoke with gale, as per
rep, claim was processed on 04/24/04 and paid $35. Allowed amount is $50. Check # is 001608527.
Check was cashed on 05/02/04. It’s a single check. Check was sent to the address po box-600728,
Austin, Tx-77339. Claim # is 04258fe234f00. Requested for copy of an explanation of benefits and
cancelled check copy to be mailed.
1.2.2. Claim denied for untimely filing:

1. When was the claim denied?
Claim denied on 08/24/04.
2. When the claim was received the first time?
Claim was received on 08/15/04.
3. May I have the timely filing limit?
Its 90 days from the date of service.
5. If filed with the timely limit, need to ask, Can we
appeal the claim with proof of timely filing?
If yes, need to ask
6. What is the timely appealing limit?
60 days from the date of denial.
7. May I have the appealing address?
BCBS TX, Appeals dept, po box-6067, Austin,
Tx-78526.
Request for copy of an explanation of benefits if not received

rep, claim was processed on 08/24/04 and denied for untimely filing as they received the claim past the
timely filing limit. Timely filing limit is 90 days from the date of service. Claim # is 04258fe234f00. So
need to appeal the claim with the proof of timely filing to the appealing address BCBS TX, Appeals
dept, po box-6067, Austin, Tx-78526. Requested for copy of an explanation of benefits to be mailed.
1.2.3. Claim denied as duplicate:

For duplicate submission:
1. When was the claim denied?
Claim was denied on 04/24/04.
Inform rep that, two similar services were performed on the same day, if claim was taken for
reprocess, use the appropriate issue code, if not, ask,
2. Can we send the send medical records that state the
medical necessity of two similar services on the same
day?
If yes, get the address to send the records.
3. May I have the address where the records to be sent?
BCBS TX, po box-6067, Austin, Tx-78526.
4. Do we need to attach any special form with he records?
If yes, get the type of form to be attached.
Request for copy of an explanation of benefits if not received.

rep, claim was processed on 04/24/04 and denied as duplicate as they have already paid a similar claim
for the same date of service for the same provider for the same procedure and for the same diagnosis
code. Claim # is 04258fe234f00. So need to send medical records that states the medical necessity of
two similar codes on the same day with the provider adjustment form to the address BCBS TX, po box-
6067, Austin, Tx-78526.
If the claim was taken for reprocess,
1. May I have the claim # under which the claim was taken for
reprocess?
2. May I have the processing time of the claim?
20 days.
Called blue cross and blue shield of Texas at 800-451-0287 and spoke with gale, as
per rep, claim was processed on 04/24/04 and denied as duplicate. Informed rep that service was
rendered by two different doctors for two different diagnosis codes, rep took the claim for reprocess.
Claim # is 04258fe234f00. Processing time is 20 days. So we need to follow up after 20 days.
For Duplicate Charge:

This denial is almost similar to the duplicate submission
except the number of units performed. So we need to inform the rep about the multiple units performed
and request for reprocess. Lest, need to act accordingly by sending medical records.
1.2.4. Claim denied as Incidental or Inclusive:

Get the denial date and claim #,
1. May I have the primary procedure code to which
this code was bundled?
2. Can we send medical records to process these
codes separately?
If yes, get the medical records mailing
address.
Called blue cross and blue shield of Texas at 800-451-0287 and spoke
with gale, as per rep, claim was processed on 04/24/04 and denied as inclusive. As per rep this code was
included to the primary procedure code 99213 and we can send medical records to review these codes.
So need to send medical records to the address BCBS TX, po box-6067, Austin, Tx-78526. claim # is
04258fe234f00.
1.2.5. Claim denied as Bundled:

1. May I have the reason for bundling these codes?
2. Can we send medical records to process these
codes separately?
If yes, get the medical records mailing
address.
Called blue cross and blue shield of Texas at 800-451-0287 and spoke with
gale, as per rep, claim was processed on 04/24/04 and denied as bundled. As per rep the codes 84443,
85025 and 80053 are bundled together as the panel tests cannot be billed separately and we can send
medical records to unbundle these codes. So need to send medical records to the address BCBS TX, po
box-6067, Austin, Tx-78526. Claim # is 04258fe234f00.
1.2.6. Claim denied as Global:

1. May I have the global period for this service?
gale, as per rep, claim was processed on 04/24/04 and denied as global. As per rep the post operative
period is 90 days from the date of surgery. Claim # is 04258fe234f00. So need to verify and take
necessary action. Requested for copy of an explanation of benefits to be mailed.
1.2.7. Claim is in Process:

1. When was the claim received?
Received on 04/17/04
2. May I have the turnaround time for processing of
claims?
30 days from the date of receipt.
3. Is the claim pending or do you need any
additional information to process the claim?
If yes, get the info and act accordingly.
If it is refiled or corrected claim, then need to confirm the receipt of corrected
information. If the claim is in pending review for a long time, escalate the issue to the supervisor and
request for expedition of claim.
Issue code to be entered:
Called blue cross and blue shield of Texas at 800-451-0287 and
spoke with gale, as per rep, claim was received on 04/17/04 and still pending in review. Turnaround time
for processing is 30 days. Requested rep to expedite the process by escalating the issue to the supervisor
(Spoke to the supervisor and requested to expedite the process with high priority). Claim # is
04258fe234f00. So we need to follow up after 20 days.
1.2.8. Claim denied for the need of Pre-existing review

information or Pre-existing condition.
If denied for Pre-existing review information,
Get the date of denial, then
1. From whom do you need the additional information?
From both patient and provider.
2. When was the letter sent to them requesting this info?
Letter sent on the same date of denial.
3. What information you have requested from them?
Requested medical records from the provider and the
other doctor’s info from the patient to determine the Pre-
existing condition.
4. Have you received any response from them?
If yes, request for reprocess or request them to send
another letter to the patient and the provider and get the
address where this information has to be sent.
Get the claim # and send medical records to get the claim processed.
If denied as Pre-existing condition,
Get the date of denial, then
1. Have you reviewed the claim with necessary documents?
If yes, get the claim # and transfer the bill to
patient.
Get the claim # and bill the patient.
Issue code to be used:

Called blue cross and blue shield of Texas at 800-451-0287 and spoke with gale, as per rep,
claim was processed on 04/24/04 and denied for the need of pre-existing review information from both
the patient and provider. Letter was sent to the patient and the provider on 04/24/04. They need medical
records for the period from 04/02/03 to 04/02/04. So need to send the medical records to the address
BCBS TX, po box-6067, Austin, Tx-78526. Also need to request the patient to send the other doctors
information. Claim # is 04258fe234f00.
1.2.9 Claim denied as Medicare denied:

Get the denial date, then
1. May I have the reason for not covering the Medicare
denied bills?
This is a medicare supplement policy that
does not cover medicare denied bills.
Get the claim # and request for explanation of benefits if not received.
If the claim paid by refilling the corrected claim to medicare, inform rep about the
reprocessed claim payment and send the primary paid eob to get the claim paid.

per rep, claim was processed on 04/24/04 and denied as medicare denied as they are the medicare
supplemental policy under which they do not cover medicare denied claims. Claim # is 04258fe234f00.
Requested for copy of an explanation of benefits to be mailed.
1.2.10. Claim denied as not medically necessary:

Get the denial date and the claim #, then
1. Can we send medical records that state the medical
necessity of this procedure performed?
If yes, get the medical records filing address.
2. Should we appeal the claim with records?
If yes, take appropriate action.
(If the claim was denied as not a medically necessary service, this should also be sent to
the coding department to verify the diagnosis, before sending medical records).
Request for explanation of benefits if not received.
Called blue cross and blue shield of Texas at 800-451-0287 and spoke with gale,
as per rep, claim was processed on 04/24/04 and denied as not medically necessary. As per rep, we can
appeal the claim with medical records to the appealing address BCBS TX, po box-6067, Austin, Tx-
78526. Claim # is 04258fe234f00. Requested for copy of an explanation of benefits to be mailed.
1.2.11. Claim denied as patient not eligible.

1. Was the patient terminated or not eligible for the date of
service?
If terminated get the terminated date. If not eligible for
the date of service, get the patients effective date.
Request for explanation of benefits if not received.
per rep, claim was processed on 04/24/04 and denied as patient was not eligible for the date of service as
the patient if eligible only from 05/01/04. Claim # is 04258fe234f00. Requested for copy of an
explanation of benefits to be mailed.
1.2.12. Claim applied towards patient’s deductibles.
Get the processed date, then
1. May I have the amount that was applied towards the
patient’s deductibles?
$35
2. May I have the allowed amount?
$35
3. May I know the reason why it was applied towards the
patient’s deductibles?
Patient has yearly deductibles to be met.
4. Was the claim processed as in-network?
Yes
5. May I have the patient’s yearly deductible amount and the
amount yet to be met by the patient?
Patient has $300 as yearly deductibles and $173
is yet to be met.
Get the claim # and request for explanation of benefits if not received.
gale, as per rep, claim was processed on 04/24/04 and applied the allowed amount of $35 towards
patient’s deductibles. Patient has $300 as yearly deductibles and $173 is yet to be met. Claim # is
04258fe234f00. Requested for copy of an explanation of benefits to be mailed.
1.2.13. Claim applied towards patients out of pocket expenses (or

patient’s responsibility).
It’s almost similar to the deductibles. In this we need not ask the
network information.
Notes also are similar to the deductibles.
1.2.14. Claim denied for the need of primary eob.

Get the denial date, then
1. Should we send only the primary eob or do we need to send a
new claim attached with the primary eob?
Need to send only the primary eob.
Get the claim # and eob mailing address and request for explanation of benefits if not
received.
gale, as per rep, claim was processed on 04/24/04 and denied for the need of primary explanation of
benefits as they received the claim without it. So need to send only the primary eob to the address BCBS
TX, po box-6067, Austin, Tx-78526. Claim # is 04258fe234f00. Requested for copy of an explanation of
benefits to be mailed.
1.2.15. Claim denied for prior authorization.
Get the denial date, and verify the system for
authorization, if we have one give the auth and request for reprocess otherwise,
1. Have you received the hospital claim with the prior
authorization?
If yes, request for reprocess. Otherwise,
2. Can we obtain retro authorization (back dated authorization)?
If yes, call the auth department and get the retro
authorization and request for reprocess. Otherwise,
3. Can we appeal the claim with medical records?
If yes, get the appealing address and appealing limit.
Also get the claim and request for explanation of benefits if not received.
gale, as per rep, claim was processed on 04/24/04 and denied for the need of authorization, as this is an
inpatient hospital stay. The payer received no hospital claim. Claim can be appealed with medical
records to the address BCBS TX, po box-6067, Austin, Tx-78526. Claim # is 04258fe234f00. Appealing
limit is 90 days from the date of denial. Requested for copy of an explanation of benefits to be mailed.
1.2.16. Claim denied for the need of referral authorization.

Get the denial date, and verify the system and validity
period of the referral for possible referral and # of visits allowed to get the claim reprocessed.
Otherwise, get the PCP’s name and telephone #. Call the PCP office and get the referral and send the
referral to the payer to have the claim processed.

gale, as per rep, claim was processed on 04/24/04 and denied for the need of referral authorization. So
called the PCP’s office and obtained the referral as ‘ef2536’ and faxed the referral info to the payer
requesting to reprocess the claim. Claim # is 04258fe234f00.
1.2.17. Claim denied for PCP information:

Get the denial date and claim #, and confirm that
patient has not selected the PCP on this plan. Call the patient and request to select the PCP to get the
claim processed.

gale, as per rep, claim was processed on 04/24/04 and denied for the need of PCP information as the
patient has not selected the PCP at the time of issuance of benefits. So called patient and requested to
select a PCP in order to get the claim processed. Claim # is 04258fe234f00.
1.2.18. Claim denied for provider information.
Get the denial date and reason for the denial,
If denied for tax id #, verify the tax id # of the provider and also in the box 25 of the hcfa form
and then refile the claim with corrected information.
If denied for individual provider #, verify this information and refile as a corrected claim.
If denied for group information, verify the group details including the facility and billing address
and refile as corrected claim. Get the claim #.

gale, as per rep, claim was processed on 04/24/04 and denied for incorrect provider #. As per rep this is a
terminated provider # and the correct provider # is BAC1957 and rep took the claim for reprocess.
Claim # 04258fe234f00.
1.2.19. Claim denied for the need of Coordination of benefits:

1. May I have the reason for the need of COB information?
It’s for the need of yearly update.
2. Have to send any questionnaire to the patient requesting
this information and I need the date of issue if you had
sent one?
Letter was sent to the patient on 05/05/04.
Request to send another letter to the patient. Then, call the patient and request to
update the file. If the denial is to determine the primary or secondary issue, request the patient to submit
the complete COB info to get the claim processed.

gale, as per rep, claim was processed on 04/24/04 and denied for the need of COB information to
determine the correct primary payer. Letter was sent to the patient on 05/05/04. Requested to send
another questionnaire. Also called the patient and requested to update this information. Claim # is
04258fe234f00.
1.2.20. Claim denied as Mutually exclusive.

1. May I have the other primary code paid which is
similar to the code billed?
gale, as per rep, claim was processed on 04/24/04 and denied as mutually exclusive. XXXXX is the
other code considered for payment. Claim # is 04258fe234f00. Requested for copy of an explanation of
1.2.21. Claim denied for information pertaining to patient. (Signature
missing, BIC, new group or id #, full time student status, date of birth)
Get the denial date and claim #.
If denied for incorrect date of birth, verify the DOB mentioned in system. If there is any
discrepancy, contact the patient and get the issued solved o have the claim processed.
If denied for student status, get the date of issuance of the request letter to the patient. Call the
patient and request to send in this information in order to get the claim processed.

Called blue cross and blue shield of Texas at 800-451-0287 and spoke
with gale, as per rep, claim was processed on 04/24/04 and denied for the need of full time student status
information from the patient. Letter was sent to the patient on 05/05/04, but no response received. So
requested to send another letter to the patient. Called and requested the patient to send this information
in order to get the claim processed. Claim # is 04258fe234f00.
1.2.22. Claim denied as not covered service:

Get the denial date and claim #, then
1. May I know the reason why this service is not
covered under this plan?
Office visits are not covered under the
indemnity plan.
gale, as per rep, claim was processed on 04/24/04 and denied, as office visits are not covered under the
patient’s policy, as this is an indemnity plan. Claim # is 04258fe234f00. Requested for copy of an
1.2.23. Claim purged.

1. May I have the time period you hold the processed
information in the system?
90 days from the date of process.
2. Can we appeal the claim to get the previously
processed information or do we need to send a
written request to obtain this information?
Need to send a written request.
Get the appealing address and request to send a letter to get the processed information.

Noted to be entered:
per rep, no claim information is available in the system for the past 90 days as they hold information in
the system only for 90 days from the date of process. So need to send a written request requesting to
give the actually processed information.
1.2.24. Claim denied for employer information.

Get the denial date and claim #
1. May I know the reason for the need of employer’s
information?
Patient has not updated the employer’s
information when the benefits issued.
2. May I have the date on which the request letter was
sent to the patient?
On 05/05/04 the letter was issued and no
response was received.
Call and request the patient to update the employer’s information.
gale, as per rep, claim was processed on 04/24/04 and denied for the need of employer’s information.
Letter was sent to the patient on 05/05/04, but no response was received. Called the patient and
requested to update the employer’s information in order to get the claim processed. Claim # is
04258fe234f00. Requested for copy of an explanation of benefits to be mailed.
1.2.25. Claim denied for invalid place of service.

Get the date of denial and claim #, then
1. What is not correct with the place of service code?
Claim was billed as inpatient hospital whereas
they did not receive any hospital claim.
2. Can we refile the claim with corrected place of service
code?
Yes you can.
Get the refilling address and request for copy of an explanation of benefits if not
received.
gale, as per rep, claim was processed on 04/24/04 and denied for invalid placed of service code as they
did not receive any hospital claim for this date of service whereas the claim was filed as inpatient. So
need to refile the claim by correcting the place of service to the address BCBS TX, po box-6067, Austin,
Tx-78526. Claim # is 04258fe234f00. Requested for copy of an explanation of benefits to be mailed.
1.2.26. Claim denied for incorrect diagnosis code:

1. What is not correct with the diagnosis code?
It’s not compatible with the procedure and
place of service billed. (Also less number of digits in
the diagnosis billed. Ex: 899 instead of 89900)
2. Can we refile the claim by correcting the code?
If yes, get the mailing address and filing
limit for corrected claims.
gale, as per rep, claim was processed on 04/24/04 and denied, as diagnosis code is incompatible with the
procedure billed. So need to refile the claim with the corrected diagnosis code to the address BCBS TX,
po box-6067, Austin, Tx-78526. Claim # is 04258fe234f00. Requested for copy of an explanation of
1.2.27. Claim denied for incorrect procedure code:

1. What is not correct with the procedure code?
It’s not compatible with the diagnosis and
place of service billed. (Also procedure billed is not
listed in the manual. Ex: 01HB)
2. Can we refile the claim by correcting the code?
gale, as per rep, claim was processed on 04/24/04 and denied, as procedure code billed is not listed in
the manual. So need to refile the claim with the corrected procedure code to the address BCBS TX, po
box-6067, Austin, Tx-78526. Claim # is 04258fe234f00. Requested for copy of an explanation of
1.2.28 Claim not on file:

1. May I verify the address where we need to file the
claim?
2. May I have the timely filing limit?
3. Was the patient eligible for the date of service billed?

gale, as per rep, claim not in the system. So need to refile the claim. Claim mailing address is BCBS TX,
po box-6067, Austin, Tx-78526. Timely filing limit is 1 year from the date of service. Patient was
eligible for the date of service with effective from 01/01/04.
1.2.29. Claim denied for incorrect modifier:

1. What is not correct with the modifier?
This modifier is not usable for this service
as per the manual.
2. Can we refile the claim by correcting the
modifier?
gale, as per rep, claim was processed on 04/24/04 and denied, as the modifier is not usable for this
service as per the manual. So need to refile the claim with the corrected or related modifier to the
address BCBS TX, po box-6067, Austin, Tx-78526. Claim # is 04258fe234f00. Requested for copy of
an explanation of benefits to be mailed.
1.2.30. Claim denied as non-participating provider:

Get the denial date and claim #, then,
Verify the network information with the tax id # and individual provider #. If the network period was
terminated before the date of service, need to intimate this to the provider.
gale, as per rep, claim was processed on 04/24/04 and denied, as the provider was not participating. As
per rep, network was terminated on 12/31/03. Claim # is 04258fe234f00. Requested for copy of an
1.2.31. Claim processed towards capitation:

Get the denial or processed date, then
1. May I have the amount that was processed towards
capitation?
2. Does the patient have any copay amount?
3. Is it possible for you to send a copy of the
provider’s capitation information?
gale, as per rep, claim was processed on 04/24/04 towards capitation, as this provider is a capitated
provider. Patient has $15 as copay. Requested to fax us the copy of the provider’s capitation information.
1.2.32. Claim paid to patient:

1. When was the claim paid?
2. May I have the amount paid to the patient?
3. May I have the reason for sending the payment to
patient?
4. Is it possible for you give us the check #?
5. Can I have the claim #?
6. Was the explanation of benefits sent to the patient?
If not, request for a copy of an eob.

gale, as per rep, claim was processed on 04/24/04 and paid $35 to the patient as the claim processed out
of network. Rep refused to give the check # as the claim paid to the patient. Claim # is 04258fe234f00.
Explanation of benefits was sent to the patient. Need to verify and bill the patient.
SI NO Denial Specification Questions to be asked
1. Paid Check date, amount allowed, paid amount, check #, patients
responsibility, check mailing address, cashed date, total amount of the
check, claim #, eob.
2. Billing deadline Denial date, claim received date, timely filing limit, appealing limit, claim
exceeded #, eob.
3. Duplicate Denial date, reason for the denial, verify for the possible payment in the
other claim, claim #, eob.
4. Inclusive Get the primary code, possibility of review with records, claim #, eob.
5. Bundled Reason for bundling, claim #, possibility of review with medical records,
claim #, eob.
6. Global Get the global period, claim #, eob.
7. Claim in process Claim received date, processing time, reason for the delay, claim #
8. Pre-existing Possibility of review with records, pre-existing details,

condition
9. Medicare denied Reason for not covering medicare denials, claim #, eob.
10. Not medically Possibility of review with medical records, appeal address, appealing
necessary limit, claim #, eob
11. Patient not eligible Termination date, effective date, claim #, eob
12. Deductibles Process date, deductibles amount, allowed amount, patients annual
deductibles, in-network details, claim #, eob.
13. Out of pocket Process date, coinsurance amount, allowed amount, patients annual out of
expenses pocket expenses amount, claim #, eob
14. Primary eob Denial date, verify mailing address, claim #
15. Prior authorization Denial date, receipt of hospital claim, possibility of obtaining retro auth,
claim #, eob
16. Referral auth Denial date, no of visits allowed, PCP’s name and telephone #, claim #
17. PCP information Denial date, Confirmation of no PCP in the benefits issued, claim #
18. Additional Denial date, details requested from the patient or the provider, letter date,
information claim #
19. COB Reason for the need of Coordination of benefits, letter date, claim #
20. Mutually exclusive Denial date, other procedure code details, claim #, eob
21. Non covered service Denial date, details of non covered services, Claim #, eob
22. Employer Details Denial date, reason for the need of employer details, letter date, claim #
23. Place of service Denial date, incorrect details of the claim, claim #
24. Diagnosis code Denial dare, incorrect details of the diagnosis code, claim #
25. NOF Claim mailing address, timely filing limit, patients eligibility
26. Modifier Denial date, incorrect details of the modifier, claim #
27. Non par provider Denial date, verify network information with the provider details, claim #
28. Capitation Process date, copay amount, date of capitation contract, claim #
29. Paid to patent Process date, reason for the payment to patient, check #, claim #, amount
paid.

AR Trainings - Basic Questions A To Z

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AR Trainings - Basic Questions A To Z

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\AR CONTENT TRAINING:

1.2 Denial Case studies.

1.2.1 Claim paid.

1.2.2. Claim denied for untimely filing:

Request for copy of an explanation of benefits if not received

1.2.3. Claim denied as duplicate:

Request for copy of an explanation of benefits if not received.

For Duplicate Charge:

1.2.4. Claim denied as Incidental or Inclusive:

1.2.5. Claim denied as Bundled:

1.2.6. Claim denied as Global:

1.2.7. Claim is in Process:

1.2.8. Claim denied for the need of Pre-existing review

Get the claim # and bill the patient.

Issue code to be used:

1.2.9 Claim denied as Medicare denied:

Issue code to be used:

1.2.10. Claim denied as not medically necessary:

1.2.11. Claim denied as patient not eligible.

1.2.13. Claim applied towards patients out of pocket expenses (or

1.2.14. Claim denied for the need of primary eob.

1.2.16. Claim denied for the need of referral authorization.

Issue code to be used:

1.2.17. Claim denied for PCP information:

Issue code to be used:

Issue code to be used:

1.2.19. Claim denied for the need of Coordination of benefits:

Issue code to be used:

1.2.20. Claim denied as Mutually exclusive.

Issue code to be used:

1.2.22. Claim denied as not covered service:

1.2.23. Claim purged.

Issue code to be used:

1.2.24. Claim denied for employer information.

1.2.25. Claim denied for invalid place of service.

1.2.26. Claim denied for incorrect diagnosis code:

1.2.27. Claim denied for incorrect procedure code:

1.2.28 Claim not on file:

Issue code to be used:

1.2.29. Claim denied for incorrect modifier:

1.2.30. Claim denied as non-participating provider:

1.2.31. Claim processed towards capitation:

1.2.32. Claim paid to patient:

Issue code to be entered:

8. Pre-existing Possibility of review with records, pre-existing details,

26. Modifier Denial date, incorrect details of the modifier, claim #

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