Authorization

Denial Occurrence:
• This denial occurs when authorization is not obtained for a service or
treatment that requires authorization.
• Authorization number can be found on Box# 23 on the CMS1500
form or Locator# 63 on the the UB04 form.
• Sometimes, the rep says the claim is denied as authorization is needed
because the provider is out of network. In that case, do not consider it as
Auth denial and follow the scenario of 242: Services not provided by
network/primary care providers.
• Prior Authorization/Pre-Authorization: It is a process of obtaining
authorization prior to performing the treatment.
• Retro Authorization: It is a process of obtaining authorization after
performing the treatment.
On Call Scenario:
Claim denied as Authorization
Absent or Missing
↓
May I get the denial date?
↓
Check in system if Auth# is Available
↙ ↘
Yes No
↓ ↓
I have the Auth#, Can you please Check place of service billed on
reprocess the claim using this Auth#? claim is 23 (Emergency) or not
↓ ↗ ↙ ↘
Rep Agrees? ↗ Yes No
↙ ↓ ↗ ↓ ↓
Yes No ↗ ↓ Do you have Auth# on file? OR
↙ ↙ ↘ ↑ Could you please Is there any hospital claim
What is turn Need to Auth# is reprocess the claim billed on same DOS where
around time send an invalid since it is an authorization# present?
for processing? corrected emergency service (The above highlighted question
↓ claim & does not require is only applicable for
May I have the ↓ Auth#? non-hospital billing claims)
claim# & call ref#? What is ↓ ↗ ↙ ↘
the time Rep Agrees? ↗ Yes No
limit to send ↙ ↘ ↗ ↓ ↓
a corrected Yes No ↓ ↓
claim? ↓ Could you please Is it possible to
↓ What is the TAT ← ← use that Auth# and obtain Retro
May I have the for reprocessing? send claim back for Authorization#?
claim# & call ref#? ↓ reprocessing? ↙ ↘
May I have the Yes No
claim# & call ref#? ↙ ↓
What is the What is the
procedure to obtain Fax# or mailing
retro Auth#? address to send
↓ an appeal?
May I have the ↓
claim# & call How much is
ref#? the time limit?
↓
May I have the
claim# & call
ref#?
Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the Auth# is available in the system and the rep agrees to reprocess
the claim then set the follow-up for the TAT provided by the rep.
• If the Auth# is available in the system and the rep denies to reprocess
the claim and asks to send a corrected claim then update the Auth# correctly
and submit the corrected claim by updating the correct billing code "7"
along with the claim number.
• If the Auth# is not available in the system and the service is an
emergency service and the rep agrees to reprocess the claim then set the
follow-up for the TAT provided by the rep.
• If the Auth# is not available in the system and the service is not an
emergency service and the rep finds Auth# on his/her system or on the
hospital claim and agrees to reprocess the claim then set the follow-up for
the TAT provided by the rep.
• If the Auth# is not available in the system and the service is not an
emergency service and the rep does not find Auth# on his/her system or on
the hospital claim but says that it is possible to obtain retro authorization
then follow the procedure given by the rep.
• The procedure of obtaining retro authorization involves filling out the
form and sending the requested documents. If the documents are available to
you then you can fill out the form and attach the documents and send them
to insurance.
• If the documents are not available then you can ask to client.
• If the Auth# is not available in the system and the service is not an
emergency service and the rep does not find Auth# on his/her system or on
the hospital claim and says that it is not possible to obtain retro authorization
then the claim must be written off. But, sometimes clients want to send an
appeal if nothing can be done. So work as per your client's instructions.
• Auth# can also be found on the Evicore website for the payers listed
on the website. This website provides the Auth# approved for the specific
CPT code under the specific time period.
• Few insurances advise contacting Evicore insurance to obtain Auth#.
so if you have website access then you can directly check if Auth# is
approved for the CPT or not else need to call Evicore insurance and find out
the details.
 No claim on file

On call analysis and Scenario:

• When getting the status as no claim on file, always check the
clearinghouse whether the claim was sent to insurance or it is rejected, if it
is rejected then work as per the rejection.
• There could be more than one CPTs billed on the same DOS or two
DOS could be billed in a single claim form, so always open the claim form
and provide the DOS range and total billed amount as mentioned in the
claim form.
• POTF stands for Proof of timely filing.
• You can consider the below proof as POTF if these occurred within
TFL.
o An initial filed claim to the same insurance which is not
received by the payer.
o Initially rejected claims.
o Initial billing to any other payer.

No claim on file
↓
May I have policy effective and termed date?
↓
Check DOS lies between effective and termed date
↙ ↘
Yes No
↓ ↓
May I have the TFL? ← ← Is there any other policy
↓ ↖ active for the patient on DOS?
Check DOS lies within TFL ↖ ↙ ↘
↙ ↘ ↖ Yes No
Yes No ↖ ↓ ↓
↓ ↓ ← May I have May I get
May I have claim Can we fax or Policy ID, Policy call ref#?
mailing address, mail the claim effective and
Payer ID and Fax#? along with POTF? termed Date?
↓ ↖ ↙ ↘
May I get call ref#? ↖ ← No Yes
↓
May I have Fax#
or Mailing address
to send claim along
with POTF?
↓
May I get call ref#?
Important Notes & Actions:
• Please take action as per your process update. Below actions can
be different from your process update.
• If the patient policy is active on DOS and DOS lies within TFL and
the payer ID & mailing address are the same as the system details then you
can resubmit the claim.
• If the payer ID provided by the rep is different than the payer ID
mentioned in the system then search for the correct payer ID, update the
correct plan code, and resubmit the claim.
• If the correct payer ID is not available then Fax the claim if the Fax#
is provided by the rep or else drop the claim through paper.
• Always give priority to the submission of a claim via payer id or Fax#
since sending a claim via mail takes a longer time.
• If the patient policy is active on DOS and DOS has crossed the TFL
and the rep confirms that you cannot fax or mail the claim along with POTF
then resubmit the claim. Once TFL denial receives then you can send an
appeal with POTF.
• If the patient policy is active on DOS and DOS has crossed the TFL
and the rep confirms that you can fax or mail the claim along with POTF
then fax/mail the claim along with POTF. (Sometimes, the client wants to
resubmit the claim instead of mailing or faxing the claim with POTF and
waiting for TFL denial, and then sending the appeal. So, work as per the
instructions.)
• If there is no POTF and the claim was billed after TFL was crossed
then the claim needs to be written off.
• If the patient's policy was inactive on DOS and the rep provided the
details of another active policy of the patient then before resubmitting the
claim update the correct policy ID given by the rep.
• If the patient's policy was inactive on DOS and no other active policy
is available then release the claim to the patient if there is no other insurance
available in the system.
• If the other insurance is available in the system then check the
eligibility for that insurance and if the policy is active on DOS then make
that insurance as primary insurance and submit the claim.
 The maximum benefit allowed

Denial Occurrence:
• Sometimes, there is a limit on a policy where certain services are
allowed to pay only for a limited dollar amount or number of visits in a year
or lifetime.
• When the insurance payment reaches that limit then this denial
occurs.
• For example, if a service is limited to pay $1,000.00 in a year and a
patient has already taken the same service 5 times in a year where the
insurance has already made the payment of a total of $1,000.00. Now, if the
patient goes for the same treatment again then insurance will not pay the
claim this time and it will not get denied as the maximum benefit exhausted
since the allowed dollar amount is already paid.
• For example, if a service is limited to pay for 5 times in a year and a
patient has already taken the same service 5 times in a year where the
insurance has made the payment for all the 5 times. Now, if the patient goes
for the same treatment again then insurance will not pay the claim this time
and it will not get denied as the maximum benefit exhausted since allowed
visits are already paid.
On Call Scenario:
Claim denied as patient has reached
the maximum benefit allowed
↓
May I get the denial date?
↓
May I know maximum benefit reached in terms of dollar or visit?
↙ ↘
In terms of Dollar In terms of Visit
↓ ↓
How much Dollar amount How many Visit is
is allowed? allowed?
↓ ↓
How much dollar amount has How much visit has patient
patient met excluding this claim? met excluding this claim?
↓ ↓
Has patient met the allowed dollar Has patient met the allowed visit
amount excluding this claim? excluding this claim?
↙ ↘ ↙ ↘
Yes No Yes No
↓ ↓ ↓ ↓
May I have the Could you please May I have the Could you please
claim# & call ref#? send the claim back claim# & call ref#? send the claim back
for reprocessing since for reprocessing since
patient has not met the patient has not met the
the allowed dollar allowed visits
amount excluding this amount excluding this
claim? claim?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
↓ ↓
May I have the May I have the
claim# & call ref#? claim# & call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If a patient has met the allowed dollar amount or visit excluding this
claim then the claim must be billed to the secondary payer/consecutive
payer or patient.
• Before billing the claim to a Secondary or Consecutive payer, need to
verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the
payer website if access is available or else call the insurance.
• If a patient policy is active for secondary or consecutive payers on
DOS then bill the claim.
 • If no other payer is active or available on DOS then release the claim
to the patient.
• When billing a claim to secondary insurance then do not change the
payer sequence i.e. do not make secondary as primary and bill the claim or
else the primary denial reason will not be sent to secondary insurance and
the claim would be denied as need primary EOB.
• If the patient has not met the allowed dollar amount or visits
excluding this claim and the rep send the claim back for reprocessing then
set the follow-up for the TAT provided by the rep.

Medical Records Requested

On Call Scenario:

Claim denied as Medical Records Requested

↓
May I get the denial date?
↓
What is the Fax# or Mailing address to send the MR?
↓
How much is the time limit to send the records?
↓
May I have the claim# & call ref#?

Important Note:
• Calculate the time limit from the denial date, if it is not crossed then
send the MR or else write off the claim if the time limit is crossed.
• Sometimes the client wants us to send MR even if the time limit is
crossed, so work accordingly.
• Always check the remark code given with the denial reason,
sometimes it provides the exact reason for denial that could differ. So follow
the AR scenario tool to work the exact denial.
 Inclusive
On Call Scenario:

Claim denied as Bundle/Inclusive

↓
May I get the denial date?
↓
To which CPT is it bundled with?
↓
What is the time limit to send corrected claim?
↓
What is the fax# or mailing address to send an appeal?
↓
May I have the claim# and Call ref#?

Important Note:

• This denial should be sent to the coding team to check if the claim
can be resubmitted by updating the modifier or not.
• If you have access to the encoder, findacode, etc. tools then you can
also check the NCCI edit between procedures. These tools will help you to
identify whether NCCI edit exists between CPTs billed on the same DOS or
not. If yes then whether it can be overridden using the appropriate modifier
or not. It also provides the most suitable modifier to override the CPT. If
CPT cannot be overridden then it should be written off.
• If the coding team response is received with a correct modifier or you
identify the correct modifier through any tools then update it and send the
corrected claim to insurance. Medicare does not accept the corrected claim,
so send a fresh claim to medicare.
• If the coding team response is received as coding is correct or you
identify that there is no NCCI edit existing through any tools then call the
insurance and ask them to reprocess the claim. if they deny then send an
appeal to insurance.
• Tools to Identify Bundle CPT Codes
 out of network benefits
Denial Occurrence:
• This denial occurs when the provider who rendered the service is not
contracted with the insurance.
• In this scenario, the claim can be paid if the patient's policy covers
out-of-network benefits.
• If the patient's policy does not cover out-of-network benefits then the
claim can be billed to the patient.
• In the HMO or EPO plan, out-of-network benefit is not covered.
• In the PPO or POS plan, out-of-network benefit is covered.

On Call Scenario:
Claim denied as non covered services
as per patient plan as provider is out of network
↓
May I get the denial date?
↓
Does patient plan cover out of network benefit?
↓
What plan does patient has? (HMO, PPO, EPO, POS)
↙ ↙ ↘ ↘
↙ ↙ ↘ ↘
HMO PPO EPO POS
↙ ↓ ↓ ↘
May I have the Could you please May I have the Could you please
claim# & call ref#? reprocess the claim claim# & call ref#? reprocess the claim
since patient plan since patient plan
does cover out of does cover out of
network benefit? network benefit?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
↓ ↓
May I have the May I have the

claim# & call ref#? claim# & call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is denied as non-covered charges under the patient plan
as the provider is out of network and the patient has a PPO or POS plan and
the rep agrees to reprocess the claim then set the follow-up for the TAT
provided by the rep.
• If the claim is denied as non-covered charges under the patient plan
as the provider is out of network and the patient has an HMO or EPO plan
then bill the claim to the secondary or consecutive payer if available or else
release it to the patient.
• Before billing the claim to a Secondary or Consecutive payer, need to
verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the
payer website if access is available or else call the insurance.
• If no other payer is active or available on DOS then release the claim
to the patient.

Claim Paid

Scenario Occurrences:
• This scenario occurs when the claim is paid but payment information
is not received yet or posted.
On Call Scenario:
Claim Paid
↓
What is the processed & paid date?
↓
What are the allowed amount, paid amount and
patient responsibility (Coins, Deductible or Co-payment)?
↓
Verify sum of PA and Patient Responsibility(PTR) equals to AA,
if not then probe the rep and get the correct information
Click here to validate payment information
↓
Was payment done through Check or EFT/Credit Card?
↙ ↘
Check EFT/Credit Card
↓ ↓
What is the check#? What is the Transaction ID?
↓ ↓
Was it Single check or Bulk check#? Was it single payment or Bulk payment?
↙ ↘ ↙ ↘
Single check Bulk Check Single payment Bulk payment
↘ ↓ ↘ ↓
↘ What is the Bulk Amount? ↘ What is the Bulk Payment Amount?
↘ ↙ ↘ ↙
May I have the check mailing address? Is payment cleared?

↓ ↙ ↓ ↘
Validate address provided by rep with Yes Not Provided No
the address available in box# 32 and 33 ↓ ↓ ↓
↙ ↘ ↓ ↓ ↓
Correct Incorrect ↓ ↓ ↓
↓ ↘ May I have the ↓ EFT/Credit card
Is the check cashed? ↘ encashment date ↓ payment takes 2-3
↙ ↘ ↘ → → → ↘ ↓ ↙ days for clearance
Yes No ↘ Provide correct Could you please but not more than
↓ ↓ Rep does not check mailing fax the EOB? If 7 days. So, if the paid
May I have the ↓ have encashment address to rep & not then mail it or date has crossed 7 days
encashment ↓ date information? ask to reissue new provide the source then it means payment
date? ↓ ↓ check to get the EOB might get cancelled. So,
↓ ↓ Could you please ↓ ↘ verify same with rep &
Could you please Is paid date fax the EOB? If rep agrees? May I have ask rep to reissue new
fax the EOB? If crossed 45 days? not then mail it ↙ ↘ the Claim# & payment
Not then mail it ↙↘ or provide the source Yes No Call ref ↓
or provide the ↙ ↘ to get the EOB ↓ ↘ rep agrees?

source to get the ↙ ↘ ↘ What is the TAT? What is the ↙ ↘

EOB Yes No ↘ ↓ reason? Yes No
↓ ↓ ↘ → May I have ↓ ↓ ↓
May I have the Could you please How many days the claim# & Can I get the fax# What is What is the
claim# & Call run check tracker will it take to Call ref#? or mailing address TAT? reason?
ref#? to get the current clear the check? to send W9 form ↓ ↓
status of the check? ↓ to update the correct ↓ Could you
↓ Could you please address? May I have please fax the
Rep agrees fax the EOB? If ↓ the Claim# & the EOB? If
↙ ↘ not then mail it May I have the Call ref#? not then mail
Yes No or provide the source Claim# & Call ref#? it or provide
↓ ↓ to get the EOB the source to
What is the TAT? ↓ ↓ the EOB
↓ ↓ May I have the ↓
Could you please fax the EOB? Claim# & Call ref#? May I have
If not then mail it or provide the the claim# &
source to get the EOB call ref#?
↓
May I have the Claim#
& Call ref#?
Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is paid through a check on the correct address and the
check is encashed and you receive the EOB then you can note the account
and send the EOB it for posting.
• If the claim is paid through a check on the correct address and the
check is encashed and you do not receive the EOB then you can note the
account.
• If the claim is paid through a check on the correct address and the
check is not encashed and paid date has crossed 45 days and the rep agrees
to run the check tracer to get the status of the check then you can set the
follow-up for TAT provided by the rep.
• If the claim is paid through a check on the correct address and check
is not encashed and paid date has crossed 45 days and the rep denies to run
the check tracer then you can note the account.
• If the claim is paid through a check on the correct address and check
is not encashed and paid date has not crossed 45 days then you can set
follow-up for the days that will take to clear to check.
• If the claim is paid through a check on the correct address and check
encashment detail is not available and you receive the EOB then you can
note the account and send the EOB for posting.
• If the claim is paid through a check on the correct address and check
encashment detail is not available and you do not receive the EOB then you
can note the account.
• If the claim is paid through a check on an incorrect address and the
rep agrees to reissue a new check then you can set the follow-up for the
TAT provided by the rep.
• If the claim is paid through a check on an incorrect address and the
rep denies to reissue a new check then you can send a W9 form to insurance
if available.
• Most of the time rep denies to reissue a new check when they do not
find the correct mailing address. So, we need to send a W9 form to update
the mailing address.
• If the W9 form is not available then you can take the action as per the
update. A W9 form needs to be asked to the client.
• If the claim is paid through EFT or Credit Card and the payment is
cleared and you receive the EOB then you can note the account and send the
EOB for posting.
• If the claim is paid through EFT or Credit Card and the payment is
cleared and you do not receive the EOB then you can note the account.
• If the claim is paid through EFT or Credit Card and the payment
clearance information is not available and you receive the EOB then you can
note the account and send the EOB for posting.
• If the claim is paid through EFT or Credit Card and the payment
clearance information is not available and you do not receive the EOB then
you can note the account.
• If the claim is paid through EFT or Credit Card and the payment is
not cleared and paid date has crossed 7 days and the rep agrees to reissue a
new check then you can set the follow-up for the TAT provided by the rep.
• If the claim is paid through EFT or Credit Card and the payment is
not cleared and paid date has crossed 7 days and the rep denies to reissue a
new check then you can note the account.
 Duplicate

On Call Scenario:
Claim denied as duplicate
↓
May I get the denial date?
↓
Check if CPT of your charge billed
more than once on same DOS
↙ ↘
No Yes
↙ ↓
What is the original Check if modifier, rendering provider
status of the claim? and medical records are same
↓ ↙ ↘
Follow AR scenario tool No Yes
for original claim status ↓ ↓
Click Here Can you please reprocess May I have the
the claim since modifier, claim# & call ref#?
rendering provider and medical
records are different?
↓
Rep Agrees?
↙ ↘
Yes No
↙ ↙ ↘
What is the TAT Rep asked to Rep asked to
for reprocessing? send corrected submit an appeal
↓ claim ↓
May I have the ↓ What is the Fax# or
claim# & call ref#? What is the Mailing address to
time frame for send an appeal?
corrected claim? ↓
↓ How much is the
May I have the time limit?
Claim# & Call ref#? ↓
May I have the
Claim# & Call ref#?

Important Note:
• When the modifier, rendering provider, and medical records are the
same for both the CPTs billed on the same DOS then the charge should be
voided.
• Sometimes, the client wants us to get the coding team clarification to
determine whether these are duplicate charges or not, so work as per client
instructions.
• When rendering providers on both the charges are different then add
77 modifier and resubmit the corrected claim.
 • When rendering providers on both the charges are the same but the
exam times are different then add 76 modifier and resubmit the corrected
claim.
• After sending the corrected claim, if the claim is again denied for the
same reason and the insurance rep denied reprocessing the claim then send
an appeal to insurance.
• When modifiers on both the charges are different and the rep denied
reprocessing the claim then send an appeal to insurance.
• Medicare does not accept the corrected claim, so send a fresh claim to
medicare.
• When sending an appeal, calculate the time limit from the denial date,
if it is not crossed then send the document, or else write off the claim if the
time limit is crossed.
• Sometimes the client wants us to send the document even if the time
limit is crossed, so work accordingly.
• Sometimes, the Rep provides status as claim denied as duplicate as it
is already paid to another provider. So follow the AR scenario tool for paid
to another provider status.
Capitation
On Call Scenario:

Claim paid directly to provider under Capitation contract/Claim

denied as patient covered under capitation or managed care plan
↙ ↘
Medicare/Medicaid Payer Other Payers
↓ ↓
May I get the denial date? May I get the processed and paid date
↓ ↓
Which managed care payer What is the AA, PA and Patient Responsibility?
is active on DOS? (Coins, Deductible or Copayment)
↓ ↓
Can I get policy ID, claim mailing May I know whether this procedure code is
address for managed care insurance? covered under Capitation or Fee for service?
↓ ↙ ↘
May I get the Claim# & Call ref#? Fee for service (FFS) Capitation
↓ ↓
Could you please send May I know the start and end
claim back for reprocessing? date of the capitation contract?
↓ ↓
What is the TAT for Check if DOS lies between
reprocessing? capitation contract start and
end date
↙ ↘
No Yes
↙ ↓
Could you please send May I get the
claim back for reprocessing? Claim# & Call
↓ ref#?
What is the TAT for
reprocessing?
↓
May I get the Claim#
& Call ref#?
Important Note:
• When this denial is given by Medicare/Medicaid insurance then
check the web portal if access is available and you will get managed care
information as HMO/MCO plan.
• When it is Medicaid payer then managed care insurance can be billed
with the same policy ID as Medicaid insurance except for BCBS payer.
• When it is Medicare payer then managed care has a different policy
ID, you can find out the correct policy ID on that insurance portal or on call.
• When this denial occurs from other payers and CPT is covered under
Capitation then it is processed under contract where a fixed amount has been
decided to pay to the provider then this claim should be written off.
• Fee for service is a plan where insurance pays each service given by
the provider, so it's the insurance's responsibility to pay each claim.

• Timely filing limit.

Denial Occurrence:
• This denial occurs when insurance receives the claim after TFL
expired.
TFL:
• TFL stands for timely filing limit.
• A timely filing limit is a time frame set by an insurance company for
providers to submit a claim.
• TFL must be calculated from the date of service (DOS).
POTF:
• POTF stands for Proof of timely filing.
• You can consider the below proofs as POTF,
o An initial filed claim to the same insurance which is not
received by the payer.
o Initially rejected claims.
o Initial billing to any other payer.
AFL:
• AFL stands for appeal filing limit.
• ATL must be calculated from the date of denial (DOD).
On Call Scenario:
Claim denied as Past timely
filing or TFL expired
↓
May I get the denial date?
↓
When did you receive the claim?
↓
How much is the Timely filing limit?
↓
Check if the claim was received within TFL
↙ ↘
Yes No
↓ ↓
Could you please send the Check if POTF available
claim back for reprocessing ↙ ↘
since the claim was received Yes No
within TFL? ↓ ↓
↓ Can we appeal with POTF? May I have
What is the TAT for reprocessing? ↓ the claim# &
↓ What is the fax# or Mailing call ref#?
May I have the claim# & address to send an appeal? &
call ref#? What is the appeal limit?
↓
May I have the claim# &
call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim was denied incorrectly and the rep send the claim back
for reprocessing then you can set the follow-up for the TAT provided by the
rep.
• If the claim was billed after TFL expired and POTF is available that
proves that we billed the claim within TFL then send an appeal to insurance.
• If the claim was billed after TFL expired and there is no POTF
available then you can adjust the claim.
• You may come across a scenario where a claim was initially billed
within TFL to different insurance and billed to current insurance after TFL
expired then you can use initial billing information as POTF and send an
appeal to insurance.
• Calculate the appeal filing limit, if it is not crossed then send the
POTF, or else write off the claim if the appeal filing limit is crossed.
• Sometimes the client wants us to send POTF even if the AFL is
crossed, so work accordingly.
• You may also come across a scenario where the claim was billed to
insurance on the last date of the TFL period but the claim was received by
insurance after the TFL expired (for example, TFL is 90 days and the claim
 was billed on 90th day to insurance but the claim was received by the
insurance on 91st day or afterward). Then you can send an appeal on such
claims with POTF to receive the payment.
•

Non-Covered Charges

Denial Occurrences:
• This denial has 2 categories:
o Non-covered charges as per patient plan
o Non-covered charges as per provider contract
• Non-covered charges as per patient plan: This denial occurs for
below reasons,
o Provider is out of network
o Non covered DX or ICD-10 code under patient policy
o Non-covered CPT code under patient policy
• Non-covered charges as per provider contract: This denial occurs
when the CPT code is non-covered under the provider contract.
On Call Scenario:
Claim denied as Non Covered Charges
↓
May I get the denial date?
↓
Is it non covered as per patient plan or provider contract ?
↙ ↘
Non covered as per patient plan Non covered as per provider contract
↓ ↓
What is the reason for non covered? What is the reason for non covered?
↙ ↓ ↘ ↙ ↘
Provider is DX or ICD-10 other CPT non covered under Other reasons
out of network non covered reasons provider contract ↓
↓ ↓ ↓ ↓ Follow AR
Click Here What is the May I Check payment history Scenario Tool
time frame to have the if payment received for same Click Here
submit the claim# & CPT with same provider from
corrected claim? call ref#? same insurance
↓ ↙ ↘
May I have the Yes No
Claim# & Call ↓ ↓
ref#? Could you please send claim What is fax# or Appeal
back for reprocessing since address to send the appeal?
we have received payment for ↓
same procedure? How much is the appeal limit?
↓ ↓
Rep Agrees? May I have the
↙ ↘ claim# & call ref#?
Yes No
↙ ↘
What is the TAT What is fax# or Appeal
for reprocessing? address to send the appeal?
↓ ↓
May I have the How much is the appeal limit?
claim# & call ref#? ↓
May I have the
claim# & call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is denied as non-covered charges under the patient plan
as the provider is out of network then click on the link to follow the
provider's out-of-network scenario.
• If the claim is denied as non-covered charges under the patient plan
as DX or ICD-10 code is non-covered then it should be sent to the coding
team for alternative diagnosis code.
• If the coding team provides an alternative code then update it and
resubmit a corrected claim.
 • If the coding team does not provide an alternative code then bill the
claim to the secondary or consecutive payer if available or else release it to
the patient.
• If the claim is denied as non-covered charges under the patient plan
for other reasons then bill the claim to the secondary or consecutive payer if
available or else release it to the patient.
• Before billing the claim to a Secondary or Consecutive payer, need to
verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the
payer website if access is available or else call the insurance.
• If no other payer is active or available on DOS then release the claim
to the patient.
• If the claim is denied as non-covered charges as per the provider
contract and if payment is received in the payment history and the rep agrees
to reprocess the claim then set the follow-up for the TAT provided by the
rep.
• If the claim is denied as non-covered charges as per the provider
contract and if the payment is received in the payment history but the rep
denies to reprocess the claim and asks to send an appeal then submit an
appeal to insurance.
• If the claim is denied as non-covered charges as per the provider
contract and if the payment has not been received in the payment history
then you can either submit an appeal or write off the claim. So work as per
your client's instructions.
• Non-covered as per provider plan denial cannot always have the CPT
issue or may differ, so follow the scenario tool as per denial reason.

coverage terminated

Denial Occurrence:
• This denial occurs when the service is performed on a date that does
not lie between the policy effective date and the policy termination date.
On Call Scenario:
Claim denied as member coverage
terminated or Policy termed
↓
May I get the denial date?
↓
May I have the policy effective and termed date?
↓
Check if DOS lies between effective and termed date
↙ ↘
Yes No
↓ ↓
Could you please send the Is there any other policy
claim back for reprocessing active for patient on DOS?
since policy active on DOS? ↙ ↘
↓ Yes No
What is the TAT for ↓ ↓
reprocessing? May I have policy ID, May I have the
↓ Policy effective and claim# & call ref#?
May I get the Claim# termed date?
& Call ref#? ↓
May I have the claim#
& call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the rep sends the claim back for reprocessing then you should set
the follow-up for the TAT provided by the rep.
• If the rep finds another policy that is active on DOS then you can
update the new policy ID and resubmit the claim.
• If the policy is inactive and there is no active policy on DOS then you
can release the claim to the patient.
• Before releasing the claim to the patient, check if any other insurance
is available or not.
• When other insurance is available then check eligibility for that
insurance on the web portal if access is available and if the patient is active
for that insurance as primary then make it primary and resubmit the claim.
• Always check previous DOS, if payment from any other insurance
was received or not. If yes, then check the eligibility for that payer for DOS
and resubmit the claim if the patient policy is active.