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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?
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?
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?
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?
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?
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?
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
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?

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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?