The document outlines various scenarios that may occur with an insurance claim and the relevant information needed for each scenario. These include claim not on file, claim in process, claim forwarded to payer, claim paid, claim paid to wrong address, claim denied for reasons such as untimely filing, eligibility, non-covered services, and more. For each scenario, it provides questions to ask the insurance representative to obtain important details like denial date, payment amount, correct procedures and codes, and requests for explanation of benefits forms.
Ar scenarios with all the points to be verified and asked
1. Claim not on file
Claims mailing address
Fax #
Whose attention the claim
has to be faxed
Effective date
Timely filing period
Verify id and group #.
May I have the claims
mailing address?
Could you please give me
the fax # and can I go ahead
and fax it your attention?
Is patient eligible for the
DOS?
May I have the filing limit for
this claim?
2. Claim in process
Date of receipt of the claim
Processing time.
Can I have the date on
which the claim was
received?
How long would that take to
process this claim?
3. Claim forwarded to the payer from the pricing
center
Date of forwarding
of claim to the payer
Payer phone
number.
Could you please
tell me the date on
which the claim was
forwarded to the
payer?
Can I know the
phone number for
the payer please?
4. Claim paid
Check #
Check date
Paid amount
Allowed amount
Patient's responsibility
Write off
Pay to address
Cashed date
Could you please tell me the
check # and check date?
How much was the allowed
amount for the claim
Can you please tell me how
much was paid for this
DOS?
Are there any write off on
this claim?
What would be patient’s
responsibility?
Can you verify the pay to
address for me please?
Was the check cashed?
5. Claim paid to wrong address
Verify pay to address
Telephone appeal to
update
W9 form
Cancelled check copy if
cashed
If not, request for stop
payment and reissue
the check.
Could you verify the pay to
address for me please?
Can you go ahead and
update your records if I give
you the correct pay to
address for the provider over
phone?
Could you please give me
the fax # and can I go ahead
and fax W9 form to your
attention?
Please fax us a copy of the
cancelled check if the check
has already been cashed
Could you please put a stop
payment for this check and
reissue the check to the
correct address?
6. Claim denied for untimely
filing
Date of denial
Re-filing and
appealing address
Verify timely filing
limit
Fax number.
May I have the denial
date and the filing limit
for this claim?
Can I have the address
where I need to appeal
for this claim?
Could you please give
me the fax # and can I
go ahead and fax it to
your attention?
7. Claim denied for eligibility
Date of denial
Effective/
termination date of
coverage
EOB request
May I have the
denial date for this
claim?
May I have the
effective /
termination date of
patients policy?
Could you please
fax / mail me a copy
of the EOB
8. Claim denied for non covered
services
Date of denial
Details of the non
covered service
Check if patient can
be billed
EOB request.
May I have the denial
date for this claim?
Could you please tell
me the services that are
not covered under this
plan?
Can we go ahead and
bill the patient for this
claim?
Can I get a copy of this
EOB faxed / mailed to
me please?
9. Claim denied for EOB from the
primary insurance
Date of denial
Information on
primary insurance if
the rep has with
their system
Fax number.
May I have the date
this claim was
denied?
Would you be able
to re-process this
claim if I were to fax
you the Primary
EOB?
10. Claim denied for cob
Date of denial
Information of the
other insurance if
they have on their
file
EOB request.
May I have the date
this claim was
denied?
Would you be able
to tell me if the
patient has any
other Insurance?
Could you fax / mail
me a copy of the
EOB?
11. Claim denied for capitation
Date of denial
If possible date of
Capitated contract
Request for EOB
May I have the date
this claim was
denied?
May I have the date
of capitated
contract?
Could you fax / mail
me a copy of the
EOB?
12. Claim denied for authorization
number
Date of denial
Check if there is any
auth in the software
mentioned for the dos
Check if they have an
auth on file for any
hospital claim for the
same dos
Fax number
EOB request.
May I have the date this
claim was denied?
Could you please tell me if
you see any authorization #
for the same DOS for the
hospital claim?
I have a authorization # in
the system, could you re-
process the claim if I give
this number to you now?
Would you be able to re-
process this claim if I were to
fax you the claim with
authorization number?
Could you fax / mail me a
copy of the EOB?
13. Claim denied for referral
Date of denial
Check if there is any
referral on the
software mentioned
for the dos
Check if provider is
participating
Fax number
EOB request.
May I have the date this
claim was denied?
I have a referral # in the
system, could you re-
process the claim if I
give this number to you
now?
Would you be able to
re-process this claim if I
were to fax you the
claim with referral
number?
Could you fax / mail me
a copy of the EOB?
14. Claim denied as bundled/
incidental/ inclusive
Date of denial
Major procedure to
which it has been
bundled
Can we appeal with
medical notes
Fax number
EOB request.
May I have the date this
claim was denied?
Could you please tell
me to which major
procedure the claim has
been bundled to?
Can I have the address
where I need to appeal
for this claim?
Could you please give
me the fax # and can I
go ahead and fax it to
your attention?
15. Claim denied for referring
physician
Date of denial
Ask if provider is the
PCP
If not ask for PCP’s
name and phone
number
Insurance fax
number
EOB request.
May I have the date this
claim was denied?
Would you be able to
reprocess this claim if I
give you the referring
physician’s name and
UPIN #?
Can I have your fax
number?
16. Claim denied for incorrect
provider
Date of denial
Correct provider info
Fax number
EOB request.
May I have the date this
claim was denied?
I have the correct
provider # in the
system, could you re-
process the claim if I
give you this
information?
Can I have your fax
number please?
17. Claim denied as primary paid
maximum
Date of denial
Allowed amount
Verify the primary
payment details
EOB request.
May I have the date this
claim was denied?
May I know the allowed
amount for this claim?
Could you please tell
me how much did the
primary pay on this
claim?
Could you fax / mail me
a copy of the EOB?
18. Claim denied for wrong
diagnosis
Date of denial
Correct diagnosis
code
Fax number
EOB request.
May I have the date this
claim was denied?
Could you please tell
me which is correct
diagnosis for this
procedure?
Can I have your fax
number please?
Could you fax / mail me
a copy of the EOB?
19. Claim denied for modifier
Date of denial
Correct modifier
Ask for fax number
EOB request.
May I have the date this
claim was denied?
Could you please tell
me which is correct
modifier for this
procedure?
Can I have your fax
number please?
Could you fax / mail me
a copy of the EOB?
20. Claim denied for pre-existing
condition
Date of denial
Pre-existing
condition
EOB request.
May I have the date this
claim was denied?
Could you tell me the
condition that was
classified as pre-
existing for this patient?
Could you fax / mail me
a copy of the EOB?
21. Claim denied as not medically
necessary
Date of denial
Appeal with medical
notes
Fax number
EOB request
May I have the date this
claim was denied?
Can I go ahead and
send the appeal with
medical notes?
Can I have your fax
number please?
Could you fax / mail me
a copy of the EOB?
22. Claim denied for untimely follow
up
Appealing address
Verify timely follow
up time
Fax number.
May I have the date this
claim was denied?
Can I go ahead and
send the appeal with
proof of timely follow
up?
Could you tell me the
follow up time for this
claim?
Can I have your fax
number please?
23. Claim denied as duplicate
Date of denial
Primary dos to
which the claim is
denied as duplicate
Appeal with medical
notes
Fax number.
May I have the date this
claim was denied?
Can I have the details of
the primary procedure
to which claim is
duplicated?
Can I go ahead and
send the appeal with
medical notes?
Can I have your fax
number please?
24. Claim denied as Offset
Date of denial
Offset dos details
Amount offset
EOB request.
May I have the date this
claim was denied?
Could you give the
details of the DOS
offset to?
How much was offset
to?
Could you fax / mail me
a copy of the EOB?
25. Claim pending for additional
information
Details of the
information required
Fax number.
Could you tell me
the information
required to process
this claim?
May I have your fax
number please?
26. Claim processed towards
patient's deductible
Processing date
Provider in or out of
network
Break up of the
benefits
EOB request.
May I know the date on
which this claims was
processed?
Is the provider out of
network?
Could you please tell
me how much was
processed towards the
deductible?
Could you fax / mail me
a copy of the EOB?
27. Claim paid to patient
Check if provider is
participating
Payment details
EOB request.
May I know when was
the claim paid to
patient?
Can I know how much
was paid to the patient?
Is the provider
participating?
Could you fax / mail me
a copy of the EOB?