The document outlines the objectives and processes for effective denial management in claim processing, including identifying common reasons for denials and implementing a structured claim management process. Key components include patient registration, charge capture, claims processing, and appeals, with an emphasis on roles played by front office, clinical, and billing staff. It also provides tools and strategies for tracking claim denials and ensuring timely resolution through appeals and communication with insurance payors.

1. Denial Management

2. Learning Objectives and Goals:
• Identify the most common
reasons for claim denials
• Define a claim management
process to implement into
your practice
• Understand claim appeals
process for contracted payors
• Effectively utilize the tools
provided to help in the
process

3. Most Common Reasons
for Poor Claim Management
• Incorrect or inadequate demographic information in
patient registration
• Non-timely entry of changes in address or insurance
information
• No copies of insurance ID cards in the medical record
• No insurance follow-up procedure
• Lack of communication between front office and
business office
• Inadequate number of staff or not focused on the task
• Lack of knowledge of Payor claim filing process

4. How to Solve the Problem

5. What is a
Claim
Management
Process?

6. Patient
Registration
Charge Capture
Charge Entry
Claims Processing
Claims
Follow-up
Claims Appeal
Payment Entry
=

7. Benefits of a claim management process
• Increased Staff efficiency
• Increased number of
claims submitted
• Reduced number of
claims denied
• Timely and accurate
payment from the payors

8. Components of an
effective Claim Management Process
Front Office Staff
Registration
Step 1: Collect patient demographic and
insurance information using a Patient
Information Form when patient calls to
make an appointment.
• Identify the specific reason for the visit
• Make sure to record the patient’s full name as it is spelled on their
insurance card

9. Components of an
effective Claim Management Process
Front Office Staff
Step 2: Verify patient’s insurance benefits
using an Insurance Verification Form.
• Many payors allow you to check benefits online
Step 3: Notify patient of benefits and
payment expectations before the
appointment.

10. Components of an
effective Claim Management Process
Front Office Staff
Check In
Step 4: Make a copy of patient’s
insurance card. Make sure
forms are completed and signed by
patient. Collect patient’s copay and
past due balances. Have the patient
sign a Payment Responsibility Form.

11. Components of an
effective Claim Management Process
Physician & Clinical Staff
Clinical Documentation
Step 5: Document in the medical record the
patient’s history, symptoms, diagnosis, and
treatment plan, including tests that are ordered.
Step 6: Document the appropriate ICD-9-CM
and CPT codes on the super bill that apply to
the patient encounter.

12. Components of an
effective Claim Management Process
Practice Staff
Check out
Step 7: Schedule next appointment and collect any
additional monies owed by patient.

13. Components of an
effective Claim Management Process
Billing/Collections Staff
Coding Verification
Step 8: Verify and review the codes provided
to ensure they match the documentation in
the medical record and enter into the system.
Claim Generation & Submission
Step 9: Generate claim, review again for accuracy, and
submit to insurance company according to guidelines.

14. Components of an
effective Claim Management Process
Billing/Collections Staff
Claim Follow up
Step 10: Follow up with the health insurance company
after the claim is submitted to ensure that it was
received.
Payment
Step 11: Verify that payment is received in accordance
with prompt payment law and the prompt payment
provision outlined in the contract with the Payor.
Appeal
Step 12: Appeal the claim according to the payor
guidelines.

15. Appeal Process
Tools

16. Top Reasons for Denials
• Invalid patient
information
• Eligibility
• No referral or pre-
authorization
• Timely Filing
• Duplicate claim
• Invalid diagnosis or
CPT code

17. Appeal Letter Templates
• Denied for Timely Filing
• Incorrect Reimbursement
• Denied stating Out of
network provider
• Request for Recoupment
denial to payor
• Prompt Payment request
to Payor
• Patient notification of claim
denial letter

18. Track Claim Denials
• Run Monthly Reports
• Review the EOB
• Identify the Payor’s basis for the denied; delayed or
partially paid claim
• Gather supporting documentation
• Review Payor Appeals Process- send the
appropriate appeal letter for the denial
• DOCUMENT! DOCUMENT! DOCUMENT!
Use a tracking device-Claim follow up log
• Get the member involved-send notification letter
and copy of appeal letter
• Continue to appeal
• Contact employer
• Contact Department of Insurance

19. Claim Denial Tools
When payment has not been received…
• Verify that the claim was received
• Send Prompt Payment appeal letter to
Payor
• Document the issue and follow up in 10
business days. If payment has not been
received, contact payor
• If no resolution is made after second
attempt, contact the LRPHO.

20. Review Appeals Process
for all Payors
Payors with specific Appeal Guidelines or Forms:
• Aetna
• Cigna
• United Healthcare

21. Claim Appeals
Tips:
• Call first-many issues can be resolved
over the phone
• Always get a reference number
• Document the name of customer service
representative
• Fax instead of mailing
• If mailing send certified return receipt

22. Remember it is a TEAM effort!
Individual commitment to a group
effort – that is what makes a team
work, a company work, a society
work and a civilization work.

23. CLAIM DENIED FOR ELIGIBILITY
• Check paid claims in PMS.
• Find which is other active insurance
• Check any notes available General
comments
Information need to collected
• Date of denial
• Effective/ termination date of coverage
• Which is primary insurance
• Claim #

24. CLAIM PENDING FOR ADDITIONAL
INFORMATION
• Details of Missing info
(Provider/Patient)
• Processed date
• Claim #
• Fax # to send the missing
info.

25. CLAIM FORWARDED TO THE PAYER
THE PRICING CENTER
• Which is the pricing Center/payer
• Claim Processing Date
• Allowed amount and Claim #/ Tracking #
• Date of forwarding of claim to the
payer/TPA
• Payer/Processing center phone number.
• Processing time to release check.

26. CLAIM DENIED FOR TIMELY
FILING
• Date when we filed the claim
• Date on which they received the claim
• Date of denial
• Verify timely filing limit
• Check the Proof available
• Confirm What kind of Proof they will accept
( Screen shot/ Ecom Proof)
• Appeal address/ Fax # (Attention)
• Appeal limit.

27. CLAIM DENIED FOR NON COVERED
SERVICES
• Details of the non covered service like Why
this service is non covered.
• Is it as per patient policy/provider contract
• If Provider Contract- Policy for non covered
• Can we appeal (Appeal details)
• If Patient policy - Check if patient can be
billed
• Date of Denial, Claim #

28. CLAIM DENIED FOR PRIMARY EOB
• Check Claim – Primary/ Secondary
• If Primary:
• Check the paid claims & find the insurance details.
• Prim: Insurance may not be primary
• Which ins is primary & from which date onwards they
became as secondary.
• If Secondary
• Fax # and Attention – to send EOB
• If Fax is not accepted – Address where to send the
EOB.

29. CLAIM DENIED FOR COB
• Check the paid claims in PMS.
• Date of denial
• Information of the other insurance if they have on
their file
• Date on which they send letter to patient
• Claim #
• Ask them to send one more letter to patient
• Bill the patient (– As per project Specifics)

30. CLAIM DENIED FOR CAPITATION
• Claim processed date
• When they paid capitation amount to
Provider.
• If possible date of Capitated contract
• Request for Capitation Roaster.
• Confirm is it based on Patient/service
• If service confirm your service covered in
this contract.

31. CLAIM DENIED FOR NO REFERRAL
• Why they require Referral
• Patient plan details
• Check other paid claims in PMS.
• Date of denial
• Check if there is any referral on the software
mentioned for the dos
• Check if provider is participating
• Fax number to send referral.
• Claim #.

32. CLAIM DENIED FOR REFERRING
PHYSICIAN
• If this Service require Referring Physician.
• Date of denial
• Ask if provider is the PCP (ref not
required)
• If not ask for PCP’s name and phone
number
• Claim # , Appeal details
• Contact PCP ( As per your project)

33. CLAIM DENIED FOR INCORRECT
PROVIDER #
• Date of denial
• Which is Correct provider # & # in the claims
form.
• If correct send for Review ( Reference # )
• Check PMS if correct refile the claim.
• Claim #

34. CLAIM DENIED FOR INCORRECT
DIAGNOSIS
• What is DX insurance received & what
we billed
• Which is correct DX.
• Check when this DX code is Deleted.
• Which is alternate DX
• Date of denial
• Claim #

35. CLAIM DENIED FOR INCORRECT
MODIFIER
• Which modifier in insurance/ PMS
• Which is the Correct modifier
• Date of denial
• Claim #
• Move to coding review ( Project
Specific)

36. CLAIM DENIED AS PRIMARY PAID
MAXIMUM
• What is coinsurance amount & Allowed amount in
primary.
• What is secondary Allowed amount
• If Allowed amount is less than primary amount
• Check which is secondary insurance
• If Commercial – Bill the patient
• If Medicaid – Send to write off (Project Specific)
• Claim #

37. CLAIM DENIED FOR PRE-EXISTING
CONDITION
• Pre Existing – Patient/Provider
• If from Provider
• When they send Questionnaire
• Request for one more Questionnaire – fax
• From which Month they require Medical records.
• Medical records - our provider / other Providers
• If other provider
• Bill the patient (Project Specific)
• If from Patient
• When they send letter to Patient.
• Request one more letter to patient
• Date of denial
• Claim # (Appeal Details)

38. CLAIM PAID TO PATIENT
• Check the reason-why paid to patient
• Provider may be non par/Accept Assignment not given.
• Check if provider is participating
• Check the Payment details
• Date of processing
• Claim #
• Bill the patient – for the Entire charge
amount

39. Thank
You!