DENIALS

DENIAL:
IT IS THE INFORMATION MENTIONED IN DENIED CLAIM EOB.
DENIED:
STOPPED THE CLAIM FROM MAKING THE PAYMENT
DENIAL MANAGEMENT:
QUESTIONS WHICH WE ARE ASKING FOR EACH DENIAL



AUTHORIZATION:(BLOCK 23)
Provider has to take permission from the INSURANCE COMPANY is called authorization.
It is of 2 types:
a) Prior authorization: It has to take permission before service
b) Retro authorization : It has to take permission after service

Explanation to TL:
 I will verify the denial.
 I will get the denied date.
 I will verify in my system whether we have any authorization number available or not.
 If authorization# is available. I will ask them to reprocess the claim.
 If authorization# is not available. I will ask for Retro authorization.
 If Retro authorization is not possible. I will ask them can I send an appeal with medical records.
 For sending an appeal, I will get the Fax number (or) Mailing address.
 I will get TFL for appeal.
 I will get claim number and reference number.

1st scenario Authorization is available:
 May I know the reason why claim was denied?
 Can I get denied date.
 I will verify in my system, If I have an authorization number for this DOS can u please verify whether it is valid or not.
 (Rep it is valid)
 Can u please send the claim back for reprocess under this authorization number?
 May I know how many days it will take to reprocess the claim?
 Can I get claim number?
 Can I get Reference number?

2nd scenario Authorization not available:
 May I know the reason why claim was denied?
 Can I get the denied date?
 Can I get retro authorization #
 Can I send an appeal with medical records?
 (Rep yes.)
 For sending an appeal, can I get fax number or mailing address
 Can I get Timely filing limit for appeal?
 Can I get claim and reference number.

AUTHORIZATION NUMBER   BLOCK IN CMS 1500 FORM  =   23 BLOCK
(Q)If Place of service is related to 23 and we have received a denial authorization what u will do in this case?
Ans: POS 23 is related to EMERGENCY. For Emergency services authorization is not needed. I will call to insurance company and I will ask them to reprocess the claim.
(Q).Who has to take permission from insurance company?
Ans: Provider  office has to take permission from Insurance Company

RENDERING PROVIDER:
      Rendering provider is the provider who provides actual service.

REFERRING PROVIDER (OR) Primary Care Physician (OR) Family Doctor :
     Referring provider is the provider who provides initial service.




REFERRAL:(BLOCK 23)
       It is the process of sending patient from one provider to another provider for special service.

Explanation of TL:
 I will verify the denial.
 I will get the denied date.
 I will verify who is the PCP(primary care physician) for this patient.
 I will verify in my system whether we have any referral# available  on this claim or not.
 I referral# is available, I will ask them to reprocess the claim.
 If referral is not available. I will ask the PCP Name and Phone Number.
 I will get the TFL for claim.
 I will get claim number and reference number.


1st scenario if Referral# available :
 May I know the reason why the claim was denied.
 Can I get denied date ?
 May I know who is PCP for this patient .
 I verified in system I have a referral number for this DOS can you please verify whether it is valid or not.
 Can you please send the claim back for reprocess.
 May I know how many days it will take to reprocess the claim.
 Can I get claim number and reference number.

2nd scenario if Referral# is not available :
 May I know the reason why the claim was denied .
 May I know the denied date ?
 May I know who is the PCP ?
 Can I get  phone number  of PCP?.
 Can I get TFL for corrected claim .
 Can I get claim number and reference number.



BUNDLE (OR) INCLUSIVE (OR) EXCLUSIVE:
        If we file a claim for an x-ray for both right hand and left hand with an CPT code of 71020 on the same day(DOS). if we file a claim for an x-ray of left hand with an cpt code 71010. We will receive this denial For this cpt code as 71010 x-ray for left hand has already included with 71020.

Explanation to TL :
 I will get denial.
 I will get denied date.
 I will ask to which primary CPT code it was included with.
 I will verify in system whether 59 modifier is available or not.
 If It is already filed with 59 modifier (I will explain to them and) I will ask them to reprocesses the claim.
 If 59 modifier  is not  available on the claim. I will ask can I send an corrected claim with  59 modifier.
 I will ask TFL for corrected claim.
 I will get claim number and reference number.

1st Scenario: If claim was already filed with 59 modifier
 May I know the denial reason?
 Can I get the line item which was dnd ?                                                                                            Can I get denied date?
 May i know to which Primary cpt code it was included with  ?
 I verified in system,  already we filed claim with 59 modifier , can u please verify it.
 (rep said: we have modifier on the claim)
 can u please reprocess the claim
 can i get claim# and ref#                    

2nd Scenario: If claim was not filed with 59 modifier
 May I know the denial reason?
 Can I get the line item which was dnd ?
 Can I get denied date?
 May i know to which Primary cpt code it was included with  ?
 Can i send corrected claim with 59 modifier
 ( Rep Said:  Yes, you can)
 can i get TFL for corrected claim
 can i get claim# and ref#                                




TIMELY FILING LIMIT(TFL):
       Each and Every insurance company will have a certain time period. We have to file the claim within that time period, if not we will receive this TFL denial.
(Note: POTFL  =  Proof of Timely Filing Limit)

Explanation to TL:
 I will verify the denial reason.
 I will get the denied date.
 I will ask TFL for the claim
 I will get the claim received date.
 If it is denied incorrectly. I will ask them to reprocess the claim.
 If it is denied correctly. I will ask can I send an appeal with POTFL(Claim Sent Report Clearing House Document).
 I will get mailing address or fax number
 I will ask TFL for appeal.
 I will get claim number and reference number.

1st Scenario claim was filed within time limit:
o May I know the reason why the claim was denied.
o Can I get denied date.
o Can I get received date and  TFL for the claim.
o Can u please verify this claim it was denied incorrectly as we filed the claim within time limit.
o Can u please send this claim back for review.
o May I know how many days it will take for reprocess the claim
o Can I get claim# and reference number.

2nd Scenario claim was filed after time limit:
 May I know the reason why the claim was denied.
 Can I get denied date.
 Can I get received date and TFL for the claim.
 Can I send an appeal with proof TFL.
 Can I get mailing address or can I get fax number (may I know to whose attention it should be sent.)
 Can I get TFL for appeal.
 Can I get claim and reference number.


Interview Questions
(Q) What  is the document  you will use for POTFL (Proof Of Timely Filing Limit)?
Ans: Claim sent report from clearing house
(Q) What is the TFL for Medicare?
Ans: Medicare TFL is 1 year





PRIMARY PAID MAXIMUM (OR) PRIMARY PAID MORE THAN SECONDARY ALLOWED AMOUNT:
                            If primary insurance paid more than the secondary insurance allowed amount then We will receive this denial.

Explanation to TL:
 I will verify the denial reason.
 I will get the denied date.
 I will  verify primary insurance paid amount in primary insurance EOB.
 I will verify  secondary insurance allowed amount in  secondary insurance fee schedule
 If primary paid more than secondary I will adjust the claim





PRIMARY EOB (OR) THIS CARE MAY BE COVERED BY ANOTHER PAYER:
     If we file a claim to the secondary insurance without primary EOB then we will receive this denial.

Explanation to TL:
 I will verify the denial reason .
 I will get the denied date.
 I will verify whether we have primary EOB or not.
 If we have a primary EOB, I will refile a claim to the secondary insurance with primary EOB .
 If claim was not filed to primary insurance and we are not having primary insurance details .
 I will call to secondary insurance. and I will get primary insurance details like insurance name patient ID and Mailing address.
 Then I will file the claim to primary insurance after verifying the eligibility.
 I will get claim number and reference number.


1st Scenario if EOB not available in system :
 May I know the reason why the claim was denied.
 May I know the denied date.
 May I know who is the primary insurance for this patient .
 Can I get primary insurance ID and mailing address.
 Can I get claim number and reference number.






MEDICALLY NOT NECESSARY:

Explanation to TL:
• I will verify denial  .
• I will get the denied date.
• I will ask them why it is denied as medically not necessary
• I Will ask can  I submit a corrected claim with appropriate  DX Code
• I Will get TFL for corrected claim
• If corrected claim is not accepted. I will ask can I send an appeal with the medical records to show the medical necessity.
• I will get mailing address or fax number( may I know whose attention it should be sent.)
• I will ask TFL for appeal.
• I will get claim number and reference number.


1st scenario if corrected claim is accepted :
o May I know the reason why the claim was denied .
o Can I get denied date.
o May I know the reason why it is denied as medically not necessary .
o Can I send an corrected claim with valid DX code.
o ( rep: yes) .
o Can I get TFL for the corrected claim.
o Can I claim number and reference number.

2nd scenario if corrected claim is not accepted :
o May I know the reason why the claim was denied
o Can I get denied date
o May I know the reason why it denied as medically not necessary.
o Can I send an corrected claim with valid DX
o ( rep: no) .
o Can  I send an appeal with medical records to show medical necessity .
o Can I get mailing address or fax number ( may I know to whose attention it should be sent) potfl (proof of timely filing limit)
o I will ask  TFL for appeal.
o I will get claim number and reference number .





CO-ORDINATE OF BENEFITS:
             Before taking policy patient has to update his other insurance details it is called Coordination  of benefits ( COB).
 (OR)
            when a patient has more than one insurance plan then patient has mention which is primary and which is secondary before taking the policy.

Explanation to TL :
 I will verify the denial reason
 I will get the denied date .
 I will verify when  patient lastly updated his co-ordination benefits .
 I will ask whether they have sent any letters to the patient or not .
 If they said they didn’t send any letter to the patient.
 I will request them to send a letter to the patient .
 If they said they already sent letter to patient .
 I will ask how many letters they have sent to patient .
 If they said they already sent three letters .
 I will  ask can  I bill the patient .
 I will get claim and reference number .


1st scenario letter sent to patient :
• May I know the denial .
• Can I get the denied date .
• May I know when patient lastly updated his co-ordination benefits .
• May I know whether you have sent any letter to the patient or not .
• (Rep we didn’t sent any letter )
• Can you please send a letter to the patient .
• Can I get claim and reference number.

2nd scenario already sent three letters :
o May I know the denial reason .
o Can I get the denied date .
o May I know when patient lastly updated his co-ordination benefits .
o Can you please verify whether you have sent any letters to patient .
o (Rep we have 3 letters).
o Can I bill the patient .
o Can I get claim and reference number .







PRE-EXISTING CONDITION:
       Before taking policy patient has to update his previous illness or disease details it is called Pre existing condition
(OR)
      If the patient having any illness or disease before taking the policy that has to mentioned at that time of taking policy. If it is not mentioned claim will be denied as pre existing condition .

Explanation  TL:
 I will verify denial reason .
 I will get denied date.
 will I verify what is pre-existing condition.
 I Will ask what is time period for Pre existing condition
 I will ask whether they have sent any letter to the patient or not .
 If they said they didn’t send any letter to the patient .
 I will request them to send a letter to the patient.
 If they said they already sent a letter to the patient.
 I will ask how many letters they have sent to patient.
 If they said  they have already sent 3 letters to patient .
 I will ask can I  bill the patient .
 I will get claim and reference number.

1st scenario Letter not sent to patient :
 May I know the denied .
 Can I get the denied date.
 May I know what is pre-existing condition.
 Can you verify whether you have sent letter to patient or not.
 Can you please send a letter to patient .
 Can I get claim and reference number.

2nd scenario Letter sent to patient:
• May I know the denied .
• Can I get denied date.
• May I know what is pre existing condition.
• Can you verify whether you have sent any letter to patient or not .
• (Rep we have already sent  THREE) .
• Can I bill the patient .
• Can I get claim and reference number.








NON-COVERED SERVICE:
        If it is denied as non covered service. We have to know it is under patient plan or providers plan.

Explanation to TL:
 I will get denial .
 I will get denied date.
 I will verify it is a non covered service under patient plan or provider plan.
 If they said it is under patient plan. I will ask reason why it is non-covered service under patient plan.
 I will ask them can I bill the patient.
 If they said it is under providers plan. I will ask the reason why it is non-covered service under provider plan..
 I will ask it is provider write-off.
 I will get claim and reference number.

1st Scenario: Non-covered service under patient plan
 May I know the denial?
 Can I get denied date?
 May I know it is a non cover service under patient plan or provider plan?
 (Rep: It is under patient paln)
 May I know the reason why it is denied as non cover service under patient plan?
 Can I bill the patient
 Can I get claim# and ref#            

2nd Scenario: Non-covered service under providers plan
 May I know the denial ?
 Can I get denied date?
 May I know it is a non cover service under patient plan or provider plan?
 May I know the reason why it is denied as non cover service under Provider plan?
 We have to take this amount as write-offs
 Can i get claim# and ref#                        

(Q) In your previous office for non-covered services you will take adjustment?
Ans: I will forward this claim for client for adjustment






ELIGIBILITY (OR) COVERAGE TERMINATED:
    If the patient plan expires before DOS, if it is active after DOS. We will receive this eligibility denial.

Explanation to TL:
 I will get denial reason .
 I will get denied date.
 I will get patient policy effective date and terminate date.
 I will verify the policy coverage.
 If it is denied incorrectly. I will ask them to reprocess the claim.
 If it is denied correctly. I will ask the patient other insurance details. If  no other insurance details found. I will ask can I bill the patient.
 I will get claim and reference number.


1st Scenario:Patient is not having coverage for this DOS
 May I know the denial reason?
 Can I get denied date?
 Can I get the patient policy effective date and termination date?                        
 May i know patient is having Secondary Insurance active for this dos?
 (Rep : No other Insurance )              
 Can i bill the patient?
 Can i get claim# and ref#  

2nd Scenario:Patient is having coverage for this DOS
 May I know the denial?
 Can I get denied date?
 Can I get  the patient policy effective date and termination date?                      
 Can u please verify this claim was dnd incorrectly as  patient is having for coverage ?
 Can u reprocess the claim ?
 May i know how many days it will take to reprocess the claim ?
 Can i get claim# and ref#                        

(Q)If patient is listed in Medicaid Insurance and we received denial coverage terminated. What you will do for this claims?
Ans: I will not bill this patient.  I will forward this claim for client assistance
Reason?
Medicaid insurance people are poor people





GLOBAL:
           Certain post operative services will not paid for a duration of time stating that it was included in previously paid surgery date of services. it is called global.

Explanation to TL:
o I will get the denial reason.
o I will get denied date.
o I will verify previously paid surgery DOS and CPT code
o I will get global period.(Global period means post operative services will not paid for a duration of time)
o I will verify DX code with surgery DOS and Denied DOS.
o If Denied DOS and Surgery DOS has different DX code. I will ask can I send an corrected claim with an appropriate modifier. I will ask TFL for corrected claim.
o If Denied DOS and Surgery DOS has Same DX code. I will forward this claim for my client assistance for adjustment.
o I will get claim number and reference number.

1st Scenario: If Denied DOS and Surgery DOS has different DX code (Corrected Claim)
 May I know the denial reason?
 Can I get denied date?
 May I know  the surgery DOS and CPT Code it was included with?
 Can I get global period?  
 Can I submit a corrected claim
 Can I get TFL for corrected claim
 Can I get claim and reference number. (need to forward these claims for coding team for appropriate modifier)

2nd Scenario:If Denied DOS and Surgery DOS has Same DX code (Adjustment Claim)
 May I know the denial reason?
 Can I get denied date?
 May I know  the surgery dos and cpt code it was included with
 Can I get global period
 Can I get claim and reference number. ( need to forward these claims for adjustments)






MAXIMUM BENEFITS MET:
      If the patient completed max benefits. If we file a claim after the benefits exceeded. We will receive this denial.

Explanation to TL:
 I will get the denial reason.
 I will get the denied date.
 I will ask them patient is enrolled in dollars plan or visits plan?
 If it is under dollars plan. I will ask them for a calendar year how many dollars is allowed for this patient
 If it is under visits plan. I will ask them for  a calendar year how many visits is allowed for this patient.
 I will ask them for which DOS patient has completed his maximum benefits.
 I will ask Can I bill the patient.
 I will get claim and reference number.

1st Scenario: IF IT IS UNDER DOLLARS LIMIT
 May I know the denial reason?
 Can I get denied date?
 May I know patient is enrolled in dollar plan or visit plan
 May I know for a calendar year for how many dollars Is allowed for this  patient
 May I know for which DOS patient has completed his maximum benefits.
 Can I bill the patient.
 Can I get claim and reference number.

2nd Scenario: IF IT  IS UNDER VISITS LIMIT
 May I know the denial reason?
 Can I get denied date?
 May I know patient is enrolled in dollar plan or visit plan
 May I know for a calendar year for how many visits  patient is allowed
 May i know for which DOS patient has completed his maximum benefits.
 Can I bill the patient
 Can I  get claim and reference number.





DUPLICATE:
             If two claims submitted to insurance and both claims having same DOS and CPT code then we will receive this denial. we have to verify whether denied it is correctly denied or not.

Explanation to TL:
 I will get denial reason.
 I will get denied date.
 I will ask to which claim it was referred as duplicate.
 I will verify the denied claim and original claim.
 If both claims having same DOS,CPT code, DX code ,Provider Name and Billed Amount.
 If it is denied correctly. I will ask the status of the original claim.
 If original claim and denied claim both are different.
 I will ask to reprocess the claim by explaining the difference.
 I will get claim and reference number.

1st Scenario: IT IS DND CORRECTLY
 May I know the denied reason?
 Can I get denied date?
 May I know to which claim it was referred as duplicate
 Can I get the original claim  cpt code, DXcode, billed amount and provider name
 Can you please wait for me for two minutes
 Can I get the status of the original claim(follow according to scenario rep said)
 Can I get claim# and ref#                          

2nd Scenario: IT IS DND INCORRECTLY
 May I know the denial reason?
 Can I get denied date?
 May I know to which claim it was referred as duplicate
 Can I get the original claim  cpt code, DX code, billed amount and provider name
(can u please wait for me for two minutes) (thank u very much for waiting)
 for this patient treatment was performed twice. so, we have submitted claim twice can u please verify the provider name on dnd claim and  paid claim.
 (rep verified  provider is different )
 Can you please reprocess the claim.
 May I know how many days need to reprocess the claim.
 Can I get claim# and ref#                        





OUT OF NETWORK PROVIDER:
         If the provider is not having agreement with insurance company then the provider will be consider as out of network provider.

Explanation to TL:
 I will get denial reason
 I will get denied date.
 I will verify the date from when provider is out of network.
 I will verify whether patient is having out of network benefits or not.
 If the patient is not having out of network benefits. I will ask can I bill the patient.
 If the patient is having out of network benefits , I will ask them to reprocess the claim.
 I will get the claim and reference number.

1st Scenario: Patient is  having out of network benefits
 May I know the denial reason?
 Can I get denied date?
 Can I get the date from when provider is out of network?
 Can you please verify patient is  having out of network benefits or not?
 (Rep patient  having benefits)
 Can you reprocess the claim?
 May I know how many days it will take to reprocess the claim ?
 Can I get claim# and ref#    

2nd Scenario: Patient is not having out of network benefits

 May I know the denial reason?

 Can I get denied date?

 Can I get the date from when provider is out of network?

 Can u please verify patient is  having out of network benefits or not?

 (rep patient is not having benefits)

 Can I bill the patient

 May I know how many days it will take to reprocess the claim?

 Can i get claim# and ref#                          

CPT CODE INCORRECT FOR DX CODE:

Explanation to TL:
• I will verify denial reason.
• I will get the denied date.
• I will verify CPT code and DX code with Rep.
• I will ask the reason why CPT code is incorrect for DX code.
• I will ask them can I refile the corrected claim with appropriate CPT code
• I will ask TFL for corrected claim.
• I will get claim number and reference number .

1st scenario CPT code is incorrect :
• May I know the reason why claim was denied
• Can I get denied date.
• Can you  tell me the denied cpt code which is incorrect for DX code.
• May I know the reason why  CPT Code is incorrect for  DX code.
• Can I submit a corrected claim with appropriate CPT code.
• Can I get TFL for corrected claim.
• Can I get claim and reference number .






MODIFIER IS INCONSISTENT WITH CPT CODE:

Explanation to TL:
• I will verify the denial reason.
• I will get the denied date.
• I will verify CPT code and modifier with REP.
• I will ask the reason why modifier is incorrect for CPT code .
• I ask them can I refile the corrected claim with the appropriate modifier.
• I will ask TFL for corrected claim .
• I will get claim number and reference number.

1st scenario Modifier is incorrect for CPT code:
• May I know the reason why claim was denied
• Can I get denied date.
• Can you verify  modifier which is incorrect for CPT code.
• May I know the reason why the modifier is incorrect for CPT code.
• Can I submit a corrected claim with appropriate modifier.
• Can I get TFL for corrected claim.
• Can I get claim and reference number .





CPT CODE EXCEEDED NO OF UNITS:

Explanation to TL:
• I will get the denial reason.
• I will get the denied date.
• I will ask for a day how many units are allowed for denied CPT code.
• I will ask them can I send an appeal with medical records.
• I will ask TFL for appeal.
• I will get mailling address OR fax number( I will ask to whose attention it should be sent )
• I will get claim and reference number.

NON - DENIALS

OFFSET

CAPITATION

CLAIM NOT FOUND

CLAIM IN PROCESS

CLAIM PAID

DEDUCTIBLE

Below are the keywords to remember:

Provider=Doctor,   

Number is denoted as #,  Claim number is mentioned as Claim#,  

Denied = Dnd, 

Date Of Service = DOS,

Timely Filing Limit =TFL

Representative= Rep

OFFSET:

    It is a simple adjustment against over payment done by insurance company from one patient account to another patient account.

Explanation to TL:

• I will get claim processed date.

• I will get the reason why claim was not paid.

• I will ask what is the allowed amount for this DOS.

• I will ask is there any patient responsibility or not.

• I will ask how much is applied for offset.

• I will ask to which patient DOS it was applied as offset.

• I will get that patient.

• I will get the date when they paid and I will get the cheque number.

• I will request EOB.

• I will get claim and reference number.

CAPITATION:

      Provider will be received a bulk amount and will be having an agreement with the insurance company for certain period of time it is called capitation. (For that time insurance company will not pay for a provider for his service to the patient who insured in the company.)

Explanation to TL:

• I will get claim processed date.

• I will ask the reason why claim was not paid.

• I will ask what is the allowed amount for this DOS.

• I will ask is there any patient responsibility.

• I will ask the date from when the  provider under capitation.

• I will forward this claim for my team leader for adjustment.

• I will get claim and reference number.

CLAIM NOT FOUND:

Explanation to TL:

• I will verify electronic payor id, if it is correct

• I Will get patient policy effective date and termination date

• I will ask TFL and I will refile the claim to insurance

QUESTIONS ON CALL, FOR CLAIM NOT FOUND

• CAN I GET electronic payer id

• CAN I GET patient policy effective date and termination date

• CAN I GET  TFL

CLAIM IN PROCESS

Explanation to TL:

 I Will get claim received date

 I Will ask normal  processing time

 I will ask  how many days they need for processing claim

 I will get claim# and ref#

CLAIM PAID:

Explanation to TL:

• I will ask the date when the claim was paid

• I will ask what is allowed amount 

• I will ask what is the paid amount and patient responsibility.

• I will ask in which mode it was paid.

• If they said it was paid through check. I will get check number and I will get the date when it was issued. 

• I will ask whether it is single check or bulk check.

• I will get check sent address.

• If they said it was paid through EFT. I will get EFT number and I will get the date when the transaction was done.

• I will ask whether it is a single transaction or bulk transaction.

• I will request EOB.

• I will get claim and reference number.

Handle On Call, Claim Paid Scenario:

• Can I get the date when the claim was paid

• Can I get allowed amount 

• Can I get the paid amount and patient responsibility?

• May I know in which mode it was paid?

PAID THRU CHEQUE:

• Can I get check number and can I get the date when it was issued. 

• May I know it is single check or bulk check?

• Can I get check sent address?

• Can I get claim and reference number.

PAID THRU EFT:

• Can I get the date when the claim was paid

• Can I get allowed amount 

• Can I get the paid amount and patient responsibility?

• May I know in which mode it was paid?

• Can I get EFT number and can I get the date when it was issued. 

• May I know it is single EFT or bulk EFT?

• Can I get claim and reference number.

Points To Remember:

1. IF PAID DATE IS MORE THAN 30 DAYS, WE HAVE TO REQUEST EOB

TO OUR FAX# OR BILLING ADDRESS

2. IF IT IS PAID THRU CHEQUE AND PAID DATE IS MORE THAN 30 DAYS NEED TO REQUEST CASHED DATE.

3. IF REP IS NOT HAVING CASHED DATE NEED TO REQUEST CHEQUE TRACER.

DEDUCTIBLE:

    The amount fixed by the insurance that patient has to satisfy after satisfying this amount insurance will pay for this medical benefits.

Explanation to TL:

 I will get claim processed date

 I will get patient annual deductible amount.

 I will ask what is the allowed amount.

 I will ask how much amount is applied towards deductible.

 I will ask how much patient has met for this DOS.

 I will get claim and reference number.

IN CALL - DEDUCTIBLE QUESTIONS

 Can I get claim processed date

 CAN I get patient annual deductible amount.

 MAY I KNOW  what is the allowed amount.

 MAY I KNOW How much amount is applied towards deductible.

 MAY I KNOW how much patient has met for this DOS.

 CAN I GET claim number

 CAN I GET reference number.

Medical Billing Terminolgy

Medical Billing Terms And Definitions:-

What is Medical Billing?
     It is the process of sending the Claim forms (CMS form 1500) to the Insurance Company on behalf of the provider office.

EOB (Explanation of Benefits)?
The statement of response which we received from the insurance company after submit a claim.
(OR)
EOB is the statement received from the insurance company.

DENIAL:
It is a statement received from the insurance company stating that they are not going to pay the claim and that statement is called "Denial".
(OR)
It is the information mentioned in denied claim EOB.

CPTCODE (OR) CURRENT PROCEDURAL TERMINOLOGY:
The treatment done by the provider to the patient is converted in to alpha numeric code is called “CPTCODE”.
CPTCODE range is 5 digits.
(OR)
CPT CODE reprents provider service.

In CMS-1500 form, CPT CODE located at Block No: 24D

Reference Book for CPT Code:  Healthcare Common Procedure Coding System (HCPCS).

It is the codes which specifies range for a specialty of provider
Specialty             CPT Code Ranges and Values
Office Visit ------------------------->:   99201 - 99499
EM (Evaluation and Management Services):-
Anesthesia  ------------------------->:   00100 - 01999
Surgery------------------------------>:   10000 - 69990
Radiology (X-ray, Scanning)---->:   70000 - 79999  
Pathology & Laboratory--------->:  80000 - 89398
To check up medicine------------->:  90281 - 99099

DIAGNOSIS CODE (OR) DX CODE:
The disease or illness of the patient is converted in to alpha numeric code is called “DIAGNOSIS CODE”. Its range is 7 digits.
(OR)
DX CODE represents the Patient Disease
In CMS-1500 form, CPT CODE located at Block No: 23
Reference Book for DX Code:
ICD 10CM (International Classification of Disease of 10th revision Clinical Modification).
It is effective from October 2015.Before that ICD 9CM was used

DOS (Date of Service)
It is the date when the treatment was taken by patient.
DOS MENTIONED IN CMS 1500  - Block 24A

REVENUE CYCLE MANAGEMENT:

The total process from Retrieving of files to AR follow up is called "RCM".

CAN YOU EXPLAIN RCM FOR ME? (OR) CAN YOU PLEASE TELL ME THE STEPS INVOLVED IN RCM?
ANS: It include process like
1 Retrieval of files from clients system.
   The next process is
2 Patient Demographics
   And after this
3 Medical Coding
4 Charge Entry
5 Transmission of claims or  patient bills
6 Cash posting and denial documentation
7 AR follow up( ACCOUNT RECEIVABLE) ------>DESIGNATION --   AR CALLER

MODIFIER:-
It is alpha numeric code that gives extra meaning to the CPT code.
BLOCK NO OF IN CMS 1500 FORM    - BLOCK NO 24 D

What are the modifiers you used in your previous office or tell me some modifiers what you know?
ANS: We have used modifiers
26-It represents physician services
TC-It represents Technical Component services
LT-It represents service done for left side organ of body
RT-It represents service done for Right side organ of body
59-It it is distinct service
76-It represents same service done twice by same provider
77-It represents same represents service done twice by different provider

Social Security Number (SSN):
It is a nine digit unique number issued to US citizens (permanent residents and temporary working residents.)
Format is     854- 46- 7896

Primary Care Physician (PCP):
PCP is the provider who provides initial care and refers the patient to the other provider for special services.
BLOCK NO WHERE IT IS MENTIONED IN CMS 1500    -    BLOCK NO 17

National Provider Identification number (NPI):
It is a 10 digit number given for every US provider by US government.
RENDERING PROVIDER NPI NUMBER IN CMS 1500   - BLOCK NO 24J
REFERRING PROVIDER OR PCP NPI NUMBER IN CMS 1500-   BLOCK NO 17B

TAX ID:
Tax payer identification number (TIN). It is a 9 digit unique number given for every provider by US government.
TAX ID NUMBER IN CMS 1500 FORM -   BLOCK NO 25

Billed AMOUNT(OR)CHARGED AMOUNT(OR)TOTAL AMOUNT
It is the total amount charged for a claim service.
BILLED AMOUNT IN CMS 1500 FORM     - BLOCK NO 28

FEE SCHEDULE:
It is the document that gives the cost for each cpt code.

ALLOWED AMOUNT:
The maximum amount fixed by the insurance company for a CPT code is based on the insurance fee schedule.

Paid Amount:
It is the amount paid to the provider by insurance.

Patient Responsibility:
It is the amount patient has to pay.
It is Co- Insurance, Co-Pay, and Deductible.
Deductible:
Patient has to satisfy certain amount which was fixed by insurance company after satisfying that amount only insurance will pay for his medical benefits.
Copay :
It is the initial amount paid to the provider before taking the service by patient
Co-Insurance:
It is patient responsibility that patient has to pay if there is no secondary insurance.


INSURANCE:-
Primary Insurance:
It is the insurance that is first responsible for making payments to the providers.
Secondary Insurance:
It is the insurance that is second responsible for making payments to the provider after the primary insurance.
Tertiary Insurance:
 It is the insurance responsible for making the payments after secondary insurance.

Co-Ordinate Benefit(COB):
Patient has to decide who is primary and who is secondary before taking policy.

Allowed Amount(AA) = Paid Amount(PA) + Patient Responsibility(PR)

Paid Amount(PA)   = Allowed Amount(AA) - Patient Responsibility(PR)

Federal Insurance Names:
MEDICARE:
It provides health care benefits for the people who are above age 65 and who are suffering from long disease and who is physically handicapped.

What are the plans involved in MEDICARE
They are four types of plan in Medicare they are
Medicare Part A: hospital coverage or it will cover inpatient
Medicare Part B:  Physician services or Outpatient
Medicare Part C: DME (Durable Medical Equipment)
Medicare Part D: Medicines

What is TFL for Medicare?
TFL for Medicare 1 year

WHAT IS MEDICARE PART-B ANNUAL DEDUCTIBLE AMOUNT?
Medicare Part B Annual Deductible amount $183.00 for 2017

Advance Beneficiary Notice?
It is a notice sent to patient by provider when they believe service will not cover by Medicare.

PTAN?
Provider Transaction Access Number (PTAN) is a number issued to providers by Medicare, after enrolling with Medicare
Medicare insurance id looks like?
It is a SSN# followed by suffix.
SSN# -   452 -30 -8619
Medicare id- 452308619A

IN WHAT CASES MEDICARE WILL PAY AS SECONDARY INSURANCE?
1. Worker Compensation
2. Auto Insurance
3. Veterans Administration insurance


MEDICAID:
 It will provide the health care benefits for the people who are below poverty line.
(OR)
It will cover health care benefits for poor people in US.

Medicaid spends down program:
If a person earnings totally spent on health care expenses. He is eligible for Medicaid spends down program.

TRICARE:-
It will provide the healthcare benefits for army people families and retired employees.
(OR)
IT WILL COVER HEATHCARE BENEFITS FOR ARMY PEOPLE IN US.

CHAMPVA:-
It will provides health care benefits for the dependents of veterans
(OR) people who are disabled in armed service.

WORK COMPENSATION:
It will provide the healthcare benefits for the employee who subjected to illness (or) accidents which happens during the work time.
(OR)
It will provide the health care benefits for the employee (who become ill or injured in worked time).

COMMERICAL INSURANCES:
Commerical Ins     PhoneNo               Corrected/Appeal Calims TFL(Days) from Denied Date
 UHC                  1 877-842-3210     90 days
 AETNA             1 800-624-0756    180 days
 CIGNA              1 800-102-4464     90 days
 HUMANA         1 800-457-4708   180 days
 QUALCHOICE                              120 days
 CARE IMPROVEMENT               120 days
 BLUE CROSS BLUE SHIELD    
 MOLINA HEALTHCARE

Place of service(POS)-
 It is the place where service is rendered.
 Office visit - 11
 In patient - 21
 Outpatient -22
 Emergency - 23
 Ambulatory services -24
 Skilled Nursing Facility- 31
 POS MENTIONED IN CMS 1500 -- Block 24B

Physical Address (OR) Facility:-
It is place where provider office or facility is located.
Facility MENTIONED IN CMS 1500 -- BLOCK NO 32

Billing Address:-
It is place where EOB and cheques are sent by insurance company .
Billing Address MENTIONED IN CMS 1500 -Block 33

Clearing House:-
It is a Middle office between provider and insurance company.

What is the clearing house you are using in previous office?
Ans: EMDEON

Rejection:
Claims will be returned from clearing office or insurance company is called rejection.

PAYMENT WILL BE MADE IN THREE WAYS:
1. CHEQUE
2. EFT (Electronic fund transfer): It is way of transferring fund electrically.
3. CREDIT CARD

Charge Sheet (OR) Super Bill (OR) Medical Records(MCR#):
Simply it is called medical records.
It contains details of provider name, Date of service, disease and service details.

Cross over claim:
When claim information is sent from a primary insurance to secondary insurance it is considered as cross over claim.
For example, claim is transferred to primary insurance Medicare and after paying the claim by Medicare. it will transfer the claim directly to secondary insurance.

HIPAA:  (Health Insurance Portability and Accountability Act)
It is Law implemented in 1996 by CMS. It is used to protect health records from third party.

Appeal:
A formal request sent to insurance company asking to reprocess the claim.
Reprocess:
If insurance denied claim incorrectly we are asking to reverify the claim to get the payment it is called Reprocess

CMS:  Centre for Medicare and Medicaid service.
HCFA: Health care financing administration. Formerly known as CMS

Assignment of Benefits(AOB):
It is a legal agreement between patient and insurance company to release funds to the provider.
AOB MENTIONED IN CMS 1500 --- BLOCK NO 13

Release of Information (ROI)- It is agreement between patient and provider to release patient health information to insurance company.
ROI MENTIONED IN CMS 1500 --- BLOCK NO 12

Claim will be sent in 3 ways
1. Electronic payer id
2. Mailing address
3. Fax#

MEDICARE INSURANCE YOU WILL TRANSFER THE CLAIMS ELECTRONICALLY OR THRU MAILING ADDRESS?
ANS:   ELECTRONICALLY

MANGED CARE PLANS:
They are four types of managed care plans they are
1 HMO (Health Maintenance Organization)
2 PPO (Preferred Provider Organization)
3 EPO (Exclusive Provider Organization)
4 POS (Point Of Service)


                                     HMO PPO EPO POS
PCP YES NO YES YES
REFERRAL YES NO YES YES
INNETWORK YES YES YES YES
OUTNETWORK NO YES NO YES
AUTHORIZATION YES YES YES YES


HMO PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE HMO PLAN, PCP IS COMPULSORY AND REFERRAL IS COMPULSORY
2. NEED TO VISIT IN-NETWORK PROVIDER  AND OUT-NETWORK PROVIDERS NOT ELIGIBLE
3. AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT  CLAIMS

PPO PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE PPO PLAN, PCP AND REFERRAL IS NOT NEEDED .
2. IN-NETWORK AND OUT-NETWORK PROVIDERS ARE ELIGIBLE
3.  AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIMS

EPO PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE EPO PLAN, PCP IS COMPULSORY AND REFERRAL IS COMPULSORY
2. NEED TO VISIT IN-NETWORK PROVIDERS  AND OUT-NETWORK PROVIDERS ARE NOT ELIGIBLE
3.  AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIMS



POS PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE POS PLAN, PCP IS COMPULSORY AND REFERRAL IS COMPULSORY
2.  IN-NETWORK AND OUT-NETWORK PROVIDERS ARE ELIGIBLE
3.  AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIMS

PTAN:
IT IS THE NUMBER GIVEN FOR EVERY US PROVIDER AFTER REGISTERING WITH MEDICARE INSURANE

CORRECTED CLAIM:
After making Necessary changes in claim form it is considered as CORRECTED CLAIM.

HOW YOU WILL SUBMIT CORRECTED CLAIM?
After making necessary changes I will type CORRECTED CLAIM in 19 TH BLOCK and I will submit to insurance company.

W9 Form:
W9 form is used for updating the provider billing office address and provider related information with insurance.

Date Of Birth Rule(DOB Rule):
According to date of birth rule, for a child primary and secondary insurance is selected (when mother and father is having insurance)
Mother 02/09/1992
Father 06/27/1990
In this case according to month decision is taken not year
Hence, Mother insurance is primary and father is secondary

Beneficiary (OR) Insured Person :
 A person eligible for receiving benefits under insurance policy. He is also called as subscriber.

HOSPICE:
It provides Medical care and Treatment for persons who will be dying soon.

Tell me about your self?

Hi, my name is xxxxx.

I was born and brought up in xxxxxx.

Coming to my educational qualification,

        I have completed my xxxxxx from xxxxxx university.

Coming to my work experience, 

       Total I have 1 year 9 months work experience as an AR Caller. 

       I worked 1 year in previous company name. Currently, I am working in current company name.

My roles are

       making calls to insurance company and getting claim status when there is no EOB.

       Working on denials according to denial management.

       Making followups on appeals and corrected claims.