AR Scenarios

AR Scenarios
R1 is a registered trademark of R1 RCM Inc. All rights reserved. Proprietary Confidential Information 1
Account Receivable
(AR) Scenarios
AR Learning Path
Day 1 Day2 Day3
• System setup, disclaimer and training • System setup, Training Agenda and • System setup, Training Agenda and
overview Quick Quiz session Quick Quiz session
• Breather • Breather • Breather
• Claim not on file, Claim in process • Claim Applied to Offset • Maximum Benefits Reached, PP MAX
• First Break • First Break • First Break
• Clearing house navigation, ID Card • Different Types of Patient • Teach Back Session
review Responsibility • Dinner Break
• Dinner Break • Dinner Break • Teach Back Session
• Quick Quiz to know how much they • Quick Quiz to check the attention • Breather
understood • Claim applied to deductible, Non • Quick Quiz to check the attention
• Mock Call Session with Trainees and covered Services • Breather
among trainees • Breather • Mock Call Session with Trainees and
• Breather • Mock Call Session with Trainees and among trainees
• Claim Paid Scenarios. Review of EOBs among trainees • Discussion on Tomorrow's Agenda
• Second Break • Second Break
• Different modes of claim payments • Ultipro Training Modules
• Quick Quiz to know how much they • Revision and Tomorrow's Agenda
understood
• Revision and Tomorrow's Agenda
AR Learning Path
Day 4 Day 5 Day6
• System setup, Training Agenda and • System setup, Training Agenda and • System setup, Training Agenda and
Quick Quiz session Quick Quiz session Quick Quiz session
• Breather • Breather • Revision
• Co-ordination of Benefits • Introduction of Provider Denials • First Break
• First Break • First Break • Quick Quiz to diffuse the tension
• Policy termed / inactive, Dependent • Additional information from provider • Mock Call Session with Trainees
not covered • Quick Quiz to diffuse the tension • Breather
• Quick Quiz to diffuse the tension • Dinner Break • Claim denied for CLIA#
• Claim Paid to Patient • Revision • Dinner Break
• Dinner Break • Breather • Ultipro Training Modules
• Ultipro Training Modules • Quick Quiz to diffuse the tension • Second Break
• Breather • Mock Call Session with Trainees and • Ultipro Training Modules
• Mock Call Session with Trainees among trainees • Discussion on Tomorrow's Agenda
• Second Break • Second Break
• Review of Eligibility scenarios • Ultipro Training Modules
• Discussion on Tomorrow's Agenda • Discussion on Tomorrow's Agenda
AR Learning Path
Day7 Day8 Day9
• System setup, Training Agenda and • System setup, Training Agenda and • System setup, Training Agenda and
Quick Quiz session Quick Quiz session Quick Quiz session
• Revision • Timely Filing Denial • Breather
• Breather • Breather • NDC Denial
• Quick Quiz • Referral • Quick Quiz
• Mock- Calls • Quick Quiz • First Break
• First Break • First Break • Claim Underpaid
• Non - par Provider Information • Mock Call Session with Trainees and • Dinner Break
• Dinner Break among trainees • Teach Back Session
• Non-Par Provider • Dinner Break • Breather
• Capitation • Credentialing • Mock Call Session with Trainees and
• Breather • Breather among trainees
• Authorization • Ultipro Training Modules • Breather
• Second Break • Quick Quiz • Ultipro Training Modules
• Authorization • Discussion on Tomorrow's Agenda • Revision and Tomorrow's Agenda
• Revision
• Discussion on Tomorrow's Agenda
AR Learning Path
Day 10 Day11 Day12
• System setup, Training Agenda • System setup, Training Agenda • System setup, Training Agenda
and Quick Quiz session and Quick Quiz session and Quick Quiz session
• Inclusive Denial • Claim denied for mising for • Inconsistent with patient's age,
• First Break missing or invalid modifier gender, invalid DX, POS
• Quick Quiz • First Break • First Break
• Global to Surgery • Quick Quiz • Revision
• Dinner Break • Claim denied as duplicate • Dinner Break
• Claim denied as not medically • Dinner Break • Mock Call Session with Trainees
necessary / experimental • Claim denied as inconsistent with and among trainees
• Breather provider speciality • Review of CMS 1500 and Revision
• Revision of the topics • Breather • Breather
• Second Break • Denied for Inconsistent DX • Revision
• Ultipro Training Modules • Mock Call Session with Trainees • Final Assessment
• Revision and Tomorrow's Agenda and among trainees • Second Break
• Second Break • Quick Activity to diffuse the
• Ultipro Training Modules tension
• Revision and Tomorrow's Agenda
AR Learning Path
Day 13
• System setup, Re-Assessment Training

Plan
• Breather
• Revise the topics that are required
• First Break
• Dinner Break
• Quick Quiz to diffuse the tension
• Breather
• Scores Sharing And Re-Assessment
Training
• Second Break
• Revision and Mock Questions
• Re-Assessment
• Quick Activity to diffuse the tension
System Set-up and Disclaimer
AR Description
▪ R1 - works on behalf of provider making sure to generate revenue for services rendered by
the provider to patients.
▪ Services are generally billed in the form of invoices raised by a business and delivered to
the insurance for payment within an agreed time frame.
▪ AR associate's follow-up on a claims which are Denied, rejected or pending with insurance
for too long, we make corrections and rebill the claims.
▪ We use websites, client software, make calls, review payer protocols to convert the denials
into provider payments.
AR Denials
Denial
▪ Denial is a determination given by insurance after they adjudicate, or process claim and
stating that the payment cannot be made on claim under certain scenario. which we would
learn under denial scenarios
▪ When a claim is denied it is categorized in the following based on the type of denial :
1. Non-Denials
2. Patient Denials
3. Provider Denials
4. Coding denials
Denials Categories
Non-Denials Provider denials Patient denials Coding Denials
Patient not on file Timely filing Non covered services Claim denied as inclusive or bundled
Claim not on file Credentialing Maximum benefits reached Claim denied as global to surgery
Claim denied as not medically
Claim in process Incorrect provider details or TAXx ID Additional information
necessary / experimental
Additional information from Claim denied for missing for missing
Claim paid to provider Deductible
provider or invalid modifier
Claim paid to patient Capitation Patient not identified Claim denied as duplicate
Claim denied as inconsistent with
Claim paid to wrong address Claim denied for authorization Policy termed / inactive
provider specialty
Claim denied as inconsistent with
Claim processed towards towards
Claim underpaid as per contract Dependent not covered patient's age, gender, invalid DX,
capitation
Place of service
Claim applied to offset Claim denied for referral Newborn not enrolled or covered Claim denied for NDC #
Claim paid to patient Claim denied for CLIA#
Provider non par Claim denied as non-covered charges
Other Insurance primary
Primary paid maximum
Relax
Refresh
Recharge
Categories of Denials
NON-DENIALS PATIENT DENIALS

In most cases, this is basically the first follow up made ▪ We get these denials if patient has not updated their
to Insurance by AR. details properly or to satisfy out of pocket expenses.
Ex: Claim not on file, Claim Paid ▪ Ex: Deductible, Non-Covered Services
CODING DENIALS PROVIDER DENIALS

▪ These are claims that denied for coding related These are the denials that are related to the provider
reasons. demographics and protocols.
▪ Ex: Invalid Combination of CPT / DX Ex: Invalid NPI or TAX ID updated to payer
Non-Denials
INTRODUCTION TO NON-DENIALS
▪ In most cases, this would be the first follow-up made by AR to get the claim status
▪ These are the set of claims wherein we haven’t received any response from Insurance
▪ There are various reasons why this happen
▪ We will now explore them one at a time
Claim Not On File
What do you understand ?
As per the insurance records there is no
Claim found for that Date of service and
billed amount
Claim Not On File If Claim is Not In
Payer System
Get Claim Mailing Call and check if

For In-Network Verify Patient
Address, Phone Active Not Active
and Out of Eligibility, Effective any other
No., Fax No &
Network Dates Of Coverage & insurance is
provider
Timely Filing Limit
status of coverage active
& Processing Time
Active Not Active
Get Insurance
Name, Address, Verify other
If Claim filed within
No Yes Phone No., ID No., Insurance details
the Timely Filing
other Insurance in Clients System.
Limit.
Information.
( per website )
Mail / Fax the Not Available
Re-Bill Claim to claim with the
Insurance for proof of TFL EDI Call that Available
processing. Report / Certified Insurance to
Mail Receipt verify eligibility. Bill the Claim to
the Insurance
If the claim gets Get Claim Mailing

denied, then claim Address, Phone
Bill the Claim to
can be adjusted as No., Fax No., Filing
Limit & Processing
the Insurance
per client
Time
Knowledge Check
1. We work on claims which are billed within 30 days

A. True
B. False
2. If the claim is rejected at the clearing house

A. We submit a new claim as it is rejected
B. Check for rejection reason and work accordingly
3. Once the claim is accepted at the clearing house

A. We ask for claim mailing address and TFL
B. Call the insurance to check the status
C. Both A & B
Claim is in process
What do you understand ?
The claim was already billed to the insurance and it is still in process
Claim is in process Check Date when
claim was sent &
received for
processing
Usual processing
time & any expected
delay due to
incomplete
information provided
If claim is in process
for a long time get
the reason for the
delay
Is additional
Provide the info No
Yes information required Get claim & call
over the phone/fax to expedite claim reference #
to the insurance processing
Provide the info

over the phone/fax
to the insurance
Knowledge Check
1. What are the questions that need to be asked when the claim is in process?
a. Check with Insurance Rep, the standard processing time.
b. Should ask representative the reason for day and about interest payment only if the normal
processing TAT (Turnaround Time) is crossed
c. Take claim received date, claim number, mark follow up date with proper notes and follow up
accordingly.
d. All the above
2. What do you mean by “claim in process”?

a. Claim rejected by the payer
b. Claim received by the payer and is in process
c. Claim received by the payer and rejected
3. If the claim is rejected at the clearing house can we check the reason for rejection ?
a. Yes
b. No R1 is a registered trademark of R1 RCM Inc. All rights reserved. Proprietary Confidential Information 20
Relax
Refresh
Recharge
Clearing House
CLEARING HOUSE
In medical billing, companies that function as intermediaries who forward claims information
from healthcare providers to insurance payers are known as clearinghouses.
▪ For Hardcopy submission we need physical address
▪ For Electronic submission Payer Id is needed
Insurance ID Card
MEDICARE – Federal BCBS – Commercial insurance
Insurance ID Card – Full View
Front Back
Practice – Mock Call
Relax
Refresh
Recharge
Mode of Payment
Card EFT – Electronic Fund Transfer Check
Claim paid to provider
What do you understand?
Claim has been received and processed by payor
After successful processing provider received payment
Payment details can be seen in the EOB
Claim paid to provider Get process/denial
date from Ins
representative
Paid Date, Allowed Amount, Get the

Patient Responsibility, Check#, information from
Single/bulk Check amount, Pay to
representative
Address, Claim #.
If the Check is If the Check is

No Info on
cashed & the paid cashed & the paid
date is less than 30 Encashment of
date is more than
check.
days. 30 days
Request for a Check Request for EOB &

Request for EOB & tracer & EOB & set copy of cancelled
set next f/u date for next f/u date for check & set next f/u
follow up. follow up. date for follow up.
Update notes and

follow up date
accordingly
EOB – Explanation of Benefits
Knowledge Check
1. When claim is paid to the correct pay to address and we do not have payment posted in our
account.
a. We must initially cross-verify for payments in the system
b. Request for a check tracer
c. Both (a) and (b)
d. None of the above
2. What are the questions which needs to be asked when claim is paid through Check?
a. Ask for check number and encashment date
b. Ask for the check Amount
c. Both (a) and (b)
d. None of the above
Relax
Refresh
Recharge
Claim paid to wrong address
What do you understand?
Claim has been processed and paid to the wrong

provider address
Possibilities
▪ Incorrect details updated to payor
▪ Provider might have changed the location
▪ Claim might have been billed with incorrect

address
Claim paid to wrong address
Yes Claim paid to the No
right address?
Verify Tax ID No.
Verify the pay-to under which the
address, date on Claim was
which claim was processed & the
processed & paid pay-to-address
• Allowed amount
• Paid amount Get payment
Yes Is the Tax ID No. & No
• Co-pay amount details from the
Pay to address
• PR (if any) representative correct?
• Provider write-off (if any)
Verify if the Check
• Check Number has been Cashed.
• Check Date Get the Check
• Total Amount on the Details
Check Get the procedure
for updating the
correct pay to
address & time
Yes No frame for same
Verify if the Check has
been Cashed
Request for a If more Send W9 form to
If more than 15 days from check tracer / stop than 180 update correct
the encashment date, Get the address & request
payment for a days from
request for a copy of encashment date to reprocess the
reissue of a new the Check
cancelled check & EOB Date claim 35
check R1 is a registered trademark of R1 RCM Inc. All rights reserved. Proprietary Confidential Information
Knowledge Check
1. What should be done when you get to know that pay to address is incorrect?
a. Ask to stop the payment
b. Check if cheque was enchased
c. Ask to cancel the cheque and request to reissue a new one
d. All the above
2. How can we update the correct address?

a. By sending W9 form
b. By sending the provider registration form
c. By calling and updating the payor
d. Ignore and proceed to the next claim
Relax
Refresh
Recharge
Thank You

AR Scenarios

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

AR Scenarios

Uploaded by

Copyright:

Available Formats

AR Scenarios

• System setup, Re-Assessment Training

NON-DENIALS PATIENT DENIALS

CODING DENIALS PROVIDER DENIALS

▪ There are various reasons why this happen

▪ We will now explore them one at a time

As per the insurance records there is no

Claim found for that Date of service and

Get Claim Mailing Call and check if

If the claim gets Get Claim Mailing

1. We work on claims which are billed within 30 days

2. If the claim is rejected at the clearing house

3. Once the claim is accepted at the clearing house

Provide the info

2. What do you mean by “claim in process”?

from healthcare providers to insurance payers are known as clearinghouses.

▪ For Hardcopy submission we need physical address

▪ For Electronic submission Payer Id is needed

MEDICARE – Federal BCBS – Commercial insurance

Card EFT – Electronic Fund Transfer Check

Claim has been received and processed by payor

After successful processing provider received payment

Payment details can be seen in the EOB

Paid Date, Allowed Amount, Get the

If the Check is If the Check is

Request for a Check Request for EOB &

Update notes and

Claim has been processed and paid to the wrong

▪ Incorrect details updated to payor

▪ Provider might have changed the location

▪ Claim might have been billed with incorrect

2. How can we update the correct address?

You might also like