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.