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.