Denail Scripit - Santosh

AR_Scenarios
Claim not on file

Could not locate the patient
Claim is in process
Coverage Terminated
Claim denied for TFL experied
Claim denied for Additional Information from Provider / Patient
Claim denied for Pre-Existing Condition
Claim denied for Out-of Netwok Provider
Claim denied for Non covered service
Claim paid to provider or patient
Claim denied for non Authorization
Claim denied for Medical Necessity
Claim denied as benefits has Exhusted
Claim Allowed amount was aplied towards deductible/ Co-ins
Claim applied towards offset
Claim applied towards Capitation
Claim denied as duplicate
Claim denied as Inclusive
Claim denied for No-Refferal
Claim Denied for Invaild ICD-9 Code or ICD-9 Code is not Matching with the CPT Code
Claim denied as Global to surgery
for future AIG 8666425246
1311
Things to remember
Must CHk if the claim mailing address is correct
If sent electronically must verify the payor ID
Never ask for the claim no
If policy active for DOS
If DOS lies within TFL If DOS lies outside TFL
May I have the mailing the Address
mailing Address/can we fax the claim to you can i have the Fax no & ATTN
Claim not on File
If policy not active for DOS
YES
e mailing the Address
Do you have the claim for the DOS we are working on .
YES NO
BACK
NO
Things to remember
We will only take the Call Ref no
Folow the SOP
Found the patient correct policy ID

Patient not indentified BACK
Patient not found

BACK

Things to remember
Once the TAT is over we will do the follow-UP
TAT--DOS- RCVD
Claim NO & Call REF # is a must
If we have called within TAT

Claim in Process
If we have called after the TAT/Delay
If the claim is approved for payment click below

Approved to pay
YES
BACK
led after the TAT/Delay
NO
Things to remember
Process date a must
Could you provide me t

BACK
Could you provide me the Claim # Call REF#

Claim denied as Coverage
If policy active for DOS than
mailing Address/can we fax the claim to you can i have the Fax no & ATTN
enied as Coverage terminated/ PT not eligible on DOS
If policy not active for DOS than
YES

BACK
NO
Claim denied for U
Things to remember
TFL is form the DOS
If the claim was received within TFL

laim denied for Untimely filing/ Past filing limit
within TFL If the claim was received afte

BACK
the claim was received after TFL

Claim denied for Addition
No response from Patient

enied for Additional information from Patient/ Provider
No response from Provide

BACK
No response from Provider

Claim denied for P
Things to remmber
Wating period is from start date of policy
If DOS lies within waiting period
Yes NO
NO Yes
laim denied for Pre existing condition
If DOS lies outside waiting period

BACK
tside waiting period

Claim denied as P
YES
w can the provider get in network with the Information

laim denied as Provider is OON
BACK
NO
BACK
Claim denied as non cove
Things to remember
Time frame is from DOS
Non covered as per Provider's contract
How can the provider get in network with the Information
Thing to remmber
enied as non covered services as per patients plan/ providers contr
der's contract
n/ providers contract
BACK
Non covered as per Patient's plan

Claim paid to Prov
Was the claim paid to provider or paitent
CLAIM PAID TO PATIENT
aa
EFT
Thing to remmber
laim paid to Provider
PR PA
Correct
Yes
BACK
0078347 72 1179.82
CHK
Incorrect
No
Claim paid to the incorrect mailling addres

ct mailling addres
Claim paid to inco
Could you provide me t
Thing to remmber
laim paid to incorrect adress
BACK

BACK
Claim paid to Patie
Thing to remmber
laim paid to Patient
BACK

BACK
Claim denied for n
Auth # found in hospital claim

laim denied for no Authorization
BACK
Auth # not found in hospital claim
YES

BACK
NO
Claim denied as Medically not ne

s Medically not necessary
BACK
me the Claim # Call REF#

Claim denied as Maximum
If PT has met the max benefits

enied as Maximum benefit met/exhausted
PT has met the max benefits If PT ha not met max benefits

BACK
Claim applied towards de
If PT has met his deductible excluding this this claim

pplied towards deductible
BACK
If PT has not met his deductible including this this cla

uctible including this this claim
Claim applied towards Off

pplied towards Offset
BACK
me the Claim # Call REF#

Claim applied towards Capitation
Things to remember
Capation can not happen for a Specalist
If Dr is PCP
DOS in capitation period

Thing to remmber
BACK
DOS not in capitation period /if Dr. is Spealist

Claim denied as Duplicat
If the information is same
Thing to remmber
enied as Duplicate claim /Duplicate charge
If Duplicate claim click here
If the information are different

BACK
Duplicate claim click here
tion are different

Claim denied as Mutually
Could you provide me the Claim #

enied as Mutually inclusive
BACK
u provide me the Claim # Call REF#

Claim denied for Referral
Things to remember
HMO/POS plan is the only plan we require referral
Found the referal
If REP says they cannot reprocess
Thing to remmber
Name Search means giving patient last name and the first name to the Insurance
Claim for Dos service is Dos we are working on is our claim DOS
We will only take the Call Ref no
enied for Referral authorization
BACK
Not found the referal
If PT has PPO/EPO plan
Insurance
BACK
If PT has HMO/POS plan

3
Claim denied as Procedure code is
Yes
If refuse to sent back for reprocessing

s Procedure code is inconsistant with Diagnosis /modifiers/place of s
BACK
No
nt back for reprocessing

modifiers/place of service code
Duplicate claim
BACK
Claim denied as G
If DOS lies within Global period

laim denied as Global to Surgery
BACK
If DOS lies outside Global period

Denail Scripit - Santosh

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Denail Scripit - Santosh

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AR_Scenarios

Claim not on file

If policy active for DOS

If DOS lies within TFL If DOS lies outside TFL

May I have the mailing the Address

If policy not active for DOS

May I have the mailing the Address

e mailing the Address

Do you have the claim for the DOS we are working on .

e mailing the Address

Found the patient correct policy ID

May I have the mailing the Address

Patient not found

May I have the mailing the Address

e mailing the Address

e mailing the Address

If we have called within TAT

If we have called after the TAT/Delay

If the claim is approved for payment click below

led after the TAT/Delay

Could you provide me t

Could you provide me the Claim # Call REF#

If policy active for DOS than

May I have the mailing the Address

If policy not active for DOS than

May I have the mailing the Address

e mailing the Address

e mailing the Address

If the claim was received within TFL

within TFL If the claim was received afte

the claim was received after TFL

No response from Patient

No response from Provide

No response from Provider

If DOS lies within waiting period

If DOS lies outside waiting period

tside waiting period

w can the provider get in network with the Information

Non covered as per Provider's contract

How can the provider get in network with the Information

Non covered as per Patient's plan

Was the claim paid to provider or paitent

CLAIM PAID TO PATIENT

How can the provider get in network with the Information

Claim paid to the incorrect mailling addres

Could you provide me t

Could you provide me the Claim # Call REF#

Could you provide me the Claim # Call REF#

Auth # found in hospital claim

May I have the mailing the Address

Auth # not found in hospital claim

May I have the mailing the Address

e mailing the Address

e mailing the Address

Could you provide me the Claim # Call REF#

me the Claim # Call REF#

How can the provider get in network with the Information

If PT has met the max benefits

PT has met the max benefits If PT ha not met max benefits

If PT has met his deductible excluding this this claim

If PT has not met his deductible including this this cla

Could you provide me the Claim # Call REF#

me the Claim # Call REF#

DOS in capitation period