Denials in Medical Billing and Actions-AR Denial Management in Medical Billing:
Whenever the claims get denied in medical billing, we need to take the following steps in order to reimburse the claims. This are the most common medical billing denials we come across in medical billing:
| Claim Paid | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim paid date | |
| 3 | May I know the claim allowed amount | |
| 4 | May I know the paid amount | |
| 5 | Is there any patient responsibility(Co-pay, Deductible, Co-ins) | |
| Check whether insurance Paid to Provider/Patient | ||
| If Provider | If Patient | |
| 6 | May I know the mode of payment whether it is EFT or Cheque | Go to Question # 8 |
| Check | EFT | |
| May I know the the check# | May I know the EFT# | |
| May I know whether it is single check or bulk check | ||
| If it is Bulk check : May I know the bulk check amount | ||
| May I know the check issued date | ||
| May I know whether the check is cashed or not( if paid date is more than 30 days from the current calling date) | ||
| May I know the check mailing address | May I know whether it is single amount for Bulk amount | |
| 7 | If check mailing address is wrong then inform the rep that check mailing address is wrong and ask her to stop the payment and request them to resend check with correct mailing address | |
| 8 | May I know any line items got denied( if the claim is more than one line item) if yes | |
| 9 | May I know the denial reason else | |
| 10 | Can I have the CPT code wise breakup details cal ref# | |
| 11 | May I know the claim# | |
| 12 | Can you please fax/send the Duplicate EOB (If paid date is more than 30 days but still not resolved then we can request the duplicate EOB) | |
| 13 | May I know the call ref# |
| Claim is in process | |
| 1 | May I know the Claim received date |
| 2 | May I know how many days it may take to process the claim |
| 3 | If the received Date is more than 30 days then need to ask below questions |
| 4 | May I know the reason for the delay |
| 5 | May I know the patient effective and termination date |
| 6 | When shall I call back to you |
| 7 | May I know the claim# |
| 8 | May I know the call ref# |
| Claim denied as Primary Paid Maximum / Primary Paid more than secondary allowed | |
| 1 | May I know the Claim received date |
| 2 | May I know the denied date |
| 3 | May I know your allowed amount for the procedure code |
| 4 | Check primary insurance paid amount in application, if it is less than the sec allowable then clarify with ins rep |
| 5 | May I know the claim# |
| 6 | May I know the call ref# |
| 7 | Could you please fax/mail the duplicate EOB |
| Claim denied as Patient cannot be identified as our insured – Adjustment Code – PR 31 in Medical Billing | |
| 1 | Could you please check with Patient Name |
| 2 | Could you please check with Patient DOB |
| 3 | Could you please check with Policy# |
| 4 | Could you please check with Patient SSN |
| 5 | Could you please check with Patient telephone# |
| 6 | Could you please check with Patient address |
| 7 | Could you please check with Patient Subscriber( If patient is not self) |
| 8 | May I know the call ref# |
| Claim denied as Duplicate Claim/Service – Denial Code OA 18 / CO 18 in Medical Billing | |
| 1 | May I know the Claim received date |
| 2 | May I know the denied date |
| 3 | May I know the original claim status |
| 4 | If original claim is denied go by the denied scenario |
| 5 | If it is paid go by the paid scenario and if it is in-process then go by the in-process scenario |
| 6 | May the original and current claim# |
| Could you please send the copy of EOB (duplicate copy) | |
| 7 | May I know the call ref# |
| Claim applied towards Deductible – PR 1 | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim was processed |
| 3 | May I know the allowed amount |
| 4 | May I know what is the amount applied towards the deductible |
| 5 | May I know whether It is in-network or out of network deductible |
| 6 | May I know the annual deductible amount for the patient(in-network/out of network) |
| 7 | May I know how much deductible met so far |
| 8 | May I know the claim# |
| 9 | May I know the call ref# |
| Coins/Copay – PR 2 / PR 3 | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim was processed |
| 3 | May I know what is the amount applied towards the copay/co-ins |
| 4 | May I know the claim# |
| 5 | May I know the call ref# |
| 6 | Could you please fax/mail the duplicate EOB |
| No claim on file or Claim not on file | |||
| 1 | May I know whether Patient effective and termination date | ||
| 2 | If eligible-active from 08/01/14 | If not eligible- | |
| 3 | May I know the TFL 90 days | May I know whether member has any other insurance/policy with u | |
| 4 | May I know the claim mailing address 501 frank avenue 300 garden cit ny1530 | If yes | If No |
| 5 | May I know the EPID | May I know the insurance Name, Policy id# and Contact# | |
| 6 | May I know the fax# and whose attention the claim should be faxed | ||
| 7 | May I know the call ref# |
| Eligibility for other insurance | ||
| May I know the Patient effective and termination date | ||
| If eligible- | If not eligible- | |
| May I know the TFL | May I know whether member has any other insurance/policy with u | |
| May I know the claim mailing address | If yes | If No |
| May I know the EPID | May I know the insurance Name, Policy id# and Contact# | |
| May I know the fax# and whose attention the claim should be faxed | ||
| May I know the call ref# |
| Claim denied as Member not eligible at the time of service | |||
| 1 | May I know whether the Patient effective and termination date | ||
| 2 | If eligible- | If not eligible- | |
| 3 | As per the policy effective and termination date this dos is eligible could you please check that and Send the claim back for reprocess. | May I know whether member has any other insurance/policy with u | |
| 4 | If yes | If No | |
| 5 | May I know the insurance Name, Policy id# and Contact# | ||
| 6 | |||
| 7 | May I know the claim# | ||
| 8 | May I know the call ref# |
| Check Eligibility for other insurance |
| Claim denied as Member coverage terminated or Policy Termed – PR 27 | |||
| 1 | May I know whether the Patient effective and termination date | ||
| 2 | If eligible- | If not eligible- | |
| 3 | As per the policy effective and termination date this dos is eligible could you please check that and Send the claim back for reprocess. | May I know whether member has been renewed his policy. If yes get the effective from | |
| 4 | May I know whether member has any other insurance/policy with u | ||
| 5 | If yes | If No | |
| 6 | May I know the insurance Name, Policy id# and Contact# | ||
| 7 | May I know the claim# | ||
| 8 | May I know the call ref# |
| Follow the protocol to check Eligibility for other insurance |
| Claim denied for COB or Co-ordination of benefits – Denial Code CO 22 | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the denied date | |
| 3 | May I know whether any letter sent to patient | |
| If Yes | If No | |
| 4 | May I know when the letter was sent to patient | Could you please send a letter to patient |
| 5 | Is there any response from the patient | |
| If Yes | If No | |
| 6 | Could you please send the claim back for reprocess | Could you please send one more letter to patient( Client specific) |
| 7 | May I know the claim# | |
| 8 | May I know the call ref# |
| Claim denied as Member enrolled in HMO/MCO | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim denied date |
| 3 | May I know the HMO/MCO insurance Name, id#, Contact#( if not available in the application) else |
| 4 | May I know the claim# |
| 5 | May I know the call ref# |
| Call HMO/MCO insurance and Check the Eligibility of the member | ||
| May I know the Patient effective and termination date | ||
| If eligible- | If not eligible- | |
| May I know the TFL | May I know whether member has any other insurance/policy with you | |
| May I know the claim mailing address | If yes | If No |
| May I know the EPID | May I know the insurance Name, Policy id# and Contact# | |
| May I know the fax# and whose attention the claim should be faxed | ||
| May I know the call ref# |
| Claim denied for Lack of information which is needed for adjudication – Denial Code CO 16 | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim was denied | |
| 3 | May I know what information is required to process the claim | |
| 4 | May I know from whom the required information is needed whether patient/provider | |
| 5 | May I know whether any letter sent to patient/Provider | |
| 6 | If Yes | If No |
| 7 | May I know when the letter was sent to patient/provider | Could you please send a letter to patient/Provider |
| 8 | Is there any response from the patient/provider | |
| 9 | If Yes | If No |
| 10 | Could you please send the claim back for reprocess | Could you please send one more letter to patient/Provider( as per Client specific) |
| 11 | May I know the claim# | |
| 12 | May I know the call ref# |
| Claim denied for Offset in Medical biling | |
| 1 | May I know when the claim was processed |
| 2 | May I know the allowed amount |
| 3 | May I know the amount applied towards offset |
| 4 | Is there any Patient responsibility |
| 5 | May I know the claim# |
| 6 | May I know to which patient is applied for offset |
| 7 | May I know the patient account# , DOS and CPT |
| 8 | May I know the reason for applied Offset adjustment |
| 9 | May I know the call ref# |
| Claim denied for Capitation | ||
| 1 | May I know when the claim was processed | |
| 2 | May I know the capitation period( contract effective and termination date) | |
| 3 | May I know the allowed amount | |
| 4 | Is there any Patient responsibility | |
| 5 | May I know whether this procedure is covered under Capitation or FFS | |
| If FFS | If Capitation | |
| Could you please send the claim back for reprocess | ||
| 6 | May I know the claim# | |
| 7 | May I know the call ref# |
| Claim denied for Maximum benefit met – PR 35 | |
| 1 | Date when the claim was received. |
| 2 | Date when the claim was denied |
| 3 | May I know the Maximum Benefit amount for the patient |
| 4 | May I know the date when the Maximum benefit amount reached |
| 5 | May I know the claim# |
| 6 | May I know the Call ref# |
| Claim denied for W9 form | |
| 1 | Date when the claim was received. |
| 2 | Date when the claim was rejected/denied |
| 3 | Need to check what is the address they have in their system and tax id |
| 4 | Need to get the address where the W9 form has to mailed or get the fax number and to whom attention the w9 form has to be sent.. |
| 5 | What is the time frame to submit the requested information.. |
| 6 | May I know the Claim# |
| 7 | May I know the Call ref# |
| Claim denied as Maximum frequency reached | |
| 1 | Date when the claim was received. |
| 2 | Date when the claim was denied |
| 3 | May I know the maximum frequency for the procedure code |
| 4 | May I know the date when maximum frequency reached |
| 5 | May I know the claim# |
| 6 | May I know the call reference# |
| 7 | Could you please fax/mail the Duplicate EOB( If it is more than 30 days from the dnd date |
| Claim denied for Primary EOB or Explanation of Benefits | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim denied date |
| 3 | May I know the Primary insurance Name, id#, Contact#( in application if primary ins not found) else |
| 4 | May I know the appeal limit and appeal address |
| 5 | May I know the fax# and whose attention claim should be faxed |
| 6 | May I know the claim# |
| 7 | May I know the call ref# |
| Claim denied for Medical Records | ||
| 1 | Date when the claim was received. | |
| 2 | Date when the claim was denied | |
| 3 | May I know why you required Medical Records for this service | |
| 4 | May I know what type of Medical Records required to process the claim | |
| 5 | May I know the appeal limit and address | |
| 6 | May I know the fax# to fax the claim with MR notes and whose attention it should be | |
| 7 | May I know the claim# | |
| 8 | May I know the Call reference# |
| Claim denied for Authorization in Medical billing | ||
| 1 | May I know the claim received date | |
| 2 | May I know the claim denied date 06/16/2017 | |
| 3 | May I know why you required authorization for this service/cpt code the provider is ouun | |
| 4 | May I know whether you have any authorization# on your file | |
| 5 | Could you please check in the hospital claim whether you have any authorization | |
| 6 | May I know whether this service is covered in that authorization | |
| 7 | May I know the effective and termination date for that authorization | |
| If yes | If No | |
| Could you please send the claim back for reprocss with that authorization | Can we get the retro authorization for this service | |
| If yes | If No | |
| Get the retro auth and ask them to send the claim back for reprocess with that auth# else | whether we can submit claim with MR notes | |
| May I know the time limit to get the retro authorization | ||
| 8 | May I know the appeal limit and address | |
| 9 | May I know the fax# and whose attention it should be faxed | |
| 10 | May I know the claim# | |
| 11 | May I know the Call reference# |
| Claim denied for Missing/invalid/Referral authorization – Denial Code CO 15 | |
| 1 | May I know the claim received date |
| 2 | May I know the claim denied date |
| 3 | Do you have any referral # on your file/records else go for 6 |
| 4 | May I know that referral # |
| 5 | Could you please send the claim back for reprocess for that referral# |
| 6 | May I know the PCP name, Contact# |
| 7 | May I know the appeal limit and appeal address |
| 8 | May I know the fax# and whose attention it should be faxed |
| 9 | May I know the claim# |
| 10 | May I know the Call reference# |
| 11 | Call PCP office and get the referral# and get the effective and termination date |
| Claim has been forwarded to pricing center | |
| 1 | May I know the claim processed date |
| 2 | May I know the Name of the repricing center |
| 3 | May I know the Batch # thru which claim was sent |
| 4 | Could you please fax the Batch face sheet |
| 5 | May I the repricing center telephone# and address |
| 6 | May I know the claim# |
| 7 | May I know the Call reference# |
| 8 | Call Repricing Center and check the status of the claim |
| Claim denied as Non covered Service | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim was denied | |
| 3 | Check in the application whether we received any patient for the previous dos if yes clarify with ins rep else next question | |
| If Yes | If No | |
| 4 | Provide the information to the rep and send the claim back for reprocess | May I know whether the CPT code is Non Covered or Diagnosis code is Non covered |
| May I know whether it is Patient plan or Provider contract | ||
| 5 | May I know the claim# | |
| 6 | May I know the call ref# |
| Claim denied for Timely Filing – Denial Code CO 29 | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | May I know the Timely Filing Limit | |
| 4 | Check whether the claim is filed within the Filing Limit and received insurance within the filing limit | |
| 5 | If Yes | If No |
| Clarify with insurance rep why they denied the claim and send the claim back for reprocess | Can we appeal with POTF | |
| 6 | Appeal Limit and appeal address and appeal Fax# and attention to | |
| 7 | May I know the claim# | |
| 8 | May I know the call ref# |
| Claim denied as Past Appealing Limit | ||
| 1 | May I know the appeal received date | |
| 2 | May I know the claim denied date | |
| 3 | May I know the appeal limit | |
| 4 | Check in the system whether the appeal was sent within the apealing limit. | |
| 5 | If Yes | If No |
| Clarify with insurance rep why they denied the claim and send the claim back for reprocess | Can we appeal again | |
| 6 | May I know the Appeal Limit and appeal address and appeal Fax# and attention to | |
| 7 | May I know the claim# | |
| 8 | May I know the call ref# |
| Claim denied as Care may be covered by another payer, per co-ordination of benefits-COB Denial Code CO 22 | |||
| 1 | May I know the Claim received date | ||
| 2 | May I know the claim denied date | ||
| 3 | May I know whether you are acting as primary/secondary/tertiary | ||
| Primary | Secondary | Tertiary | |
| 4 | clarify with insurance why they denied and send the claim back for reprocess | May I know the Primary insurance Name, id#, Contact# | May I know the secondary insurance Name, id#, Contact# |
| 5 | May I know the claim# | ||
| 6 | May I know the call ref# |
| Claim denied as Not covered by this payer or contractor – OA 109 | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim denied date |
| 3 | May I know the HMO insurance name, id#, contact#, mailing address. |
| 4 | May I know the claim# |
| 5 | May I know the call ref# |
| Voice Mail |
| Hi my name is xxxxx, I am with provider “xxxxxxx” checking on claims/bill status for the patient ” xxxxx” for the Date of Service”xxxx” for the billed amount “$xxxx”. My Call back# is “xxx-xxx-xxxx”. Again I repeat my name is xxxxx call back# is “xxx-xxx-xxxx”. I will be expecting your call. Thank you very much have a wonderful day. |
| Claim denied as Global in Medical Billing | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | May I know to which procedure code it is global | |
| 4 | May I know the date of service( which is applied global) | |
| 5 | May I know the global days for the procedure | |
| If DOS<=global days | If DOS >global days | |
| 6 | Can we appeal with modifier | Clarify with insurance rep that after the global days only the service was performed and send the claim back for reprocess |
| If yes | If No | |
| 7 | May I know the appropriate modifier for the procedure code. If rep provides then Call telephonic re-opening line update the modifier and send the claim back for reprocess | Can we appeal with Medical Records |
| Appeal Limit and appeal address and appeal Fax# and attention to | ||
| 8 | May I know the claim# | |
| 9 | May I know the call ref# |
| Claim denied as Inclusive or Bundled or Mutually exclusive | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | May I know to which procedure code it is inclusive/bundled/mutually exclusive | |
| 4 | May I know to which date of service | |
| 5 | Can we appeal with modifier | |
| If yes | If No | |
| 6 | May I know the appropriate modifier for the procedure code. If rep provides then Call telephonic re-opening line update the modifier and send the claim back for reprocess | Can we appeal with Medical Records |
| Appeal Limit and appeal address and appeal Fax# and attention to | ||
| 7 | May I know the claim# | |
| 8 | May I know the call ref# |
| Claim denied for Non participating provider | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim denied date |
| 3 | May I know the allowed amount |
| 4 | May I know whether the given tax-id is valid for the provider or not |
| 5 | Check on dos whether provider is In-network or Out of Network |
| 6 | May I know whether patient having an out of network benefits |
| 7 | May I know the claim# |
| 8 | May I know the call ref# |
| Claim denied for incorrect Place of Service | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim denied date |
| 3 | May I know the correct place of service for the procedure |
| 4 | May I know the appeal Limit and appeal address and appeal Fax# and attention to |
| 5 | May I know the claim# |
| 6 | May I know the call ref# |
| Claim denied as Missing or invalid or incomplete Modifier | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | May I know to which modifier is invalid/incomplete( if modifier submitted more than one) | |
| 4 | May I know the appropriate modifier for the procedure | |
| 5 | If Rep provides | If not provides |
| Call telephonic re-opening line update the modifier and send the claim back for reprocess( Medicare) | May I know the appeal Limit and appeal address and appeal Fax# and attention to | |
| 6 | May I know the claim# | |
| 7 | May I know the call ref# |
| Claim denied as Missing or invalid or incomplete CPT code | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | Check in application for previous DOS whether we received any payment for same CPT | |
| 4 | If yes | If No |
| Clarify with insurance and send the claim back for reprocess | May I know whether the Procedure code invalid for the Patient Age else | |
| May I know whether the Procedure code invalid for the Patient Sex else | ||
| May I know whether the Procedure code invalid for the DOS | ||
| May I know the appeal Limit and appeal address and appeal Fax# and attention to | ||
| 5 | May I know the claim# | |
| 6 | May I know the call ref# |
| Claim denied as Missing or invalid or incomplete Diagnosis code | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | Check in application for previous dos whether we received any payment for same diagnosis code | |
| If yes | If No | |
| 4 | Clarify with insurance and send the claim back for reprocess | May I know whether Diagnosis invalid for the Patient Age else |
| May I know whether Diagnosis invalid for the Patient Sex else | ||
| May I know whether Diagnosis invalid for the DOS | ||
| May I know the appeal Limit and appeal address and appeal Fax# and attention | ||
| 5 | May I know the claim# | |
| 6 | May I know the call ref# |
| Claim denied as Patient enrolled in Hospice | ||
| 1 | May I know the Claim received date | |
| 2 | May I know the claim denied date | |
| 3 | May I know the start and End date in Hospice | |
| 4 | If the dos is not in the Hospice period then call ins and send the claim back for reprocess and go to step 6 else | |
| 5 | Can we appeal with modifier | |
| If yes | If No | |
| 6 | May I know the appeal Limit and appeal address and appeal Fax# and attention to | May I know the Hospice Name and address and contact# |
| 7 | May I know the claim# | |
| 8 | May I know the call ref# | |
| Call Hospice insurance and check the eligibility |
| Missing/invalid HCFA/CMS-1500 | |
| 1 | May I know the Claim received date |
| 2 | May I know the claim denied/rejected date |
| 3 | May I know what information is missing in the HCFA/CMS-1500 |
| 4 | May I know to which field the information is missing/invalid in CMS-1500 |
| 5 | If you have the required information check with insurance rep whether they can update that information,send the claim back for reprocess then go to step 7 |
| 6 | May I know the appeal Limit and appeal address and appeal Fax# and attention to |
| 7 | May I know the claim# |
| 8 | May I know the call ref# |
| Fax Back Services | |
| 1 | Enter the Provider Tax-identification# |
| 2 | Enter the Patient Policy # |
| 3 | Enter the DOS |
| 4 | Enter the our Fax# |
| Claim denied as Not Medically Necessary | ||
| 1 | Date when the claim was received. | |
| 2 | Date when the claim was denied | |
| 3 | Check whether the CPT is not medically necessity or Diagnosis code is not medically necessity | |
| 4 | Can we appeal with Medical Records | |
| 5 | May I know the appeal limit and address | |
| 6 | May I know the fax# to fax the claim with MR notes and whose attention it should be | |
| 7 | May I know the claim# | |
| 8 | May I know the Call reference# |
| Checking Eligibility of Insurance | ||
| May I know whether member effective and termination date | ||
| If eligible- | If not eligible- | |
| May I know the TFL | May I know whether member has any other insurance/policy with u | |
| May I know whether you are acting as primary or secondary | ||
| May I know the claim mailing address | If yes | If No |
| May I know the EPID | May I know the insurance Name, Policy id# and Contact# | |
| May I know the fax# and whose attention the claim should be faxed | ||
| May I know the call ref# |
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