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Calling Template and Notes Format

Common Call Introduction 1. Hi this is Shalat calling from Doctor Office checking on claim status. 2. Provide them with the provider/doctor office information. 3. Give them our call back number. 1. Claim Paid When the claim did get paid? Get Date What is the Allowed amount? Paid amount? Patient Responsibility? Whether the patient responsibility is copay/coinsurance/deductible amount? What is the check number? Whether it is a single or bulk check? Need to verify the pay to address of the check? (Whether paid to our doctor address) Claim# and Ref# Notes Format For Dos 07/06/2011, Called Aetna @ 888-632-3862 spoke with Linda said that the claim was paid on 08/01/2011. Allowed amount $180.00, Paid amount $160.00, Copay $20.00, Paid through check# 7891234. It is a Bulk check for $2800.98, Verified pay to address and found to be correct as given in the database. Claim# 45612349000876. Ref# 89777900000000. 2. Claim Not on File Verify the effective date of the patient? What is the time frame for submission of the claim? Need to verify the mailing address for the claim/ Electronic Payer ID/ Fax# and its attention? Ref#

Notes Format For Dos 07/01/2011, Called UHC @ 877-842-3410 spoke with Debbie said that the claim is not on file. Verified eligibility and found member effective on dos effective from 01/01/2011 till date. Rep said that the TFL is 1 yr from dos. Verified mailing address to be same as that in database. Payer ID# 34567. She said that we do can fax the claim to fax# 567-812-7890 attn: Claims Department. Ref#2011987657890. 3. Claim denied for Need of Additional Information

Check when the claim was denied? What kind of additional information they need? Whether they need it from the patient or from provider? Have they sent any request letter regarding this and when they sent it? Procedure to send the additional information? Claim# and Ref# Notes Format For dos 01/01/2011, Called BCBS @ 835-563-3112 spoke with Krystal said that the claim dnd on 02/06/2011 stating need of additional information. She said that they need COB information from the patient. Rep said that they do have sent request letter for the patient on 03/04/2011 and they have not received any information as of yet. Claim# 1234567654. Ref# 23467555.

4. Claim denied for Member ID# / Name Mismatch

Check the date is of denial. Check whether there is any other member id# for the member. Need to check in our database whether there is any previous payment for the member. Claim# and Ref#. Notes Format For dos 07/01/2011, Called UHC @ 877-842-3410 spoke with Heither said that the claim denied as member id# and name mismatch. Enquired whether there is any other id# for the patient. Rep suggested to contact the patient for correct information. No other previous payments for the member. Claim# and Ref#. 5. Claim denied for Procedure code inconsistent with DX code.

Check for the denial date. Need to check regarding the details of procedure code and dx code. Need to check whether there is any payment made for similar procedure code and dx code. Need to check the time frame for submission of corrected claim. Need to check the fax# or mailing address for submission of the corrected claim.

Claim# and ref#. Notes Format For dos 05/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the procedure code is inconsistent with the dx code. Checked in database and no other previous payments for any similar procedure code with dx code, Rep said that the dx code should be changed and resubmitted as a corrected claim thru fax# 500-234-4321 attn: Claims Department. Need to mention as corrected claim. She said that the timeframe for submission of corrected claim is 60 days from date of denial. Claim# and Ref#.

6. Claim denied for Procedure code inconsistent with Modifier.

Check for the denial date. Need to check regarding the details of procedure code and dx code and Modifier. Need to check whether there is any payment made for similar procedure code, dx code and Modifier. Need to check the time frame for submission of corrected claim. Need to check the fax# or mailing address for submission of the corrected claim. Claim# and ref#. Notes Format For dos 05/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the procedure code is inconsistent with the modifier. Checked in database and no other previous payments for any similar procedure code with modifier, Rep said that the modifier should be changed and resubmitted as a corrected claim thru fax# 500-234-4321 attn: Claims Department. Need to mention as corrected claim. She said that the timeframe for submission of corrected claim is 60 days from date of denial. Claim# and Ref#.

7. Claim denied for Procedure code inconsistent with POS.

Check for the denial date. Need to check regarding the details of procedure code. Need to check whether there is any payment made for similar procedure code with the POS.

Need to check the time frame for submission of corrected claim. Need to check the fax# or mailing address for submission of the corrected claim. Claim# and ref#. Notes Format For dos 05/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the procedure code is inconsistent with the POS. Checked in database and no other previous payments for any similar procedure code with the POS, Rep said that the POS should be changed and resubmitted as a corrected claim thru fax# 500-234-4321 attn: Claims Department. Need to mention as corrected claim. She said that the timeframe for submission of corrected claim is 60 days from date of denial. Claim# and Ref#.

8. Claim Denied stating Past Timely filing limit.

Check the denial date of the claim. Enquire the date of receipt of the claim. Check what is the time frame for submission of the claim. Check the database whether the claim has been filed within the time frame or not. Enquire whether we can appeal the claim with proof of timely filing. Need to get the appealing limit, Appealing address and fax#. Claim# and Ref# Notes Format For dos 01/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the claim has been past timely filing limit. She said that the claim was rcvd on 06/25/2011 which is after the timeframe of 90 days. Told her that we do have submitted the claim on 01/05/2011 and we do have a POTFL. She suggested to appeal the claim to the appealing address United Health care, Attention Appeals Department, P.O Box 34567, Salt Lake City, Utah 32112-4567. She also provided with the fax# 345-456-8907 attn: Appeals. She said the appealing limit is 60 days from date of denial. Claim# and Ref#.

9. Claim Denied For Coverage Terminated

Check the claim denial date. Verify the effective date of the patient. If the patient is eligible on dos then need to ask rep to send it back for reprocess If not eligible need to check whether member has any other active plans for the member. If no other plans then need to check whether member has any other insurance information in our database. If no other insurance information then need to contact the patient for correct insurance information. Notes Format For dos 03/03/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the member coverage terminated. Enquired about the effective date rep said that the member effective from 10/01/1994 till 02/01/2011. She said no other plan coverage for the member. No other insurance coverage available in our database. Hence need to the contact the member for correct insurance information. Claim# and Ref#.

10.Claim Denied for Prior Auth# needed Need to check the denial date. Need to check why they need an auth# and need to check in our database for what type of service and POS and if office visit should ask why they need auth #. Need to check whether there is any auth# available in our database or need to get procedure for applying retro auth#. Claim# and ref#. Notes Format For dos 06/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the need auth#. Checked in database and found claim is for an hospital inpatient visit, Enquired whether they received the hospital claim and it is paid. She verified and said it has been paid, Enquired whether she can process with the hospital auth#. She said to contact the hospital and get the auth#. No auth# found in database. Claim# and Ref#.

11.Claim denied for need of referral number

Need to check the denial date. Need to check why they need an ref# and need to check in our database for what type of service and POS. Need to check whether there is any ref# available in our database or need to get PCP name and phone number. Claim# and ref#. Notes Format For dos 06/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the need ref#. Enquired why they need the referral number. She said that our doctor is not a PCP for this member and so they need referral number. She said that the PCP is Dr. David Campbell and his ph# is 234-567-2345. Claim# and Ref#.

12.Claim denied for Procedure code is Bundled/ Inclusive Need to check the denial date. Need to check to which procedure code is this procedure got denied as bundled or inclusive. Need to check in internet whether it is a bundled charge and ask the rep what can be done for payment of the procedure code. If there is a modifier then need ask them to reprocess or else should ask rep whether we can rebill a corrected claim with a modifier. Need to check the time frame for submission of the corrected claim. Need to ask for fax# if available to submit a corrected claim. Claim# and Ref#. Notes Format For dos 06/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the procedure code is bundled with another procedure code. Rep said that the claim denied with another procedure code on the same claim which is 99213. Told her that we do have added a modifier to the procedure code, Rep said that they do not have a modifier and asked to resubmit a corrected claim with an appropriate modifier. Enquired whether we can fax the corrected claim. Rep suggested faxing the corrected claim to fax# 345-234-6789 attn: Claims. Claim# and Ref#.

13.Claim denied for claim filed prior to coverage.

Check the claim denial date. Verify the effective date of the patient. If the patient is eligible on dos then need to ask rep to send it back for reprocess If not eligible need to check whether member has any other active plans for the member. If no other plans then need to check whether member has any other insurance information in our database. If no other insurance information then need to contact the patient for correct insurance information. Notes Format For dos 03/03/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the date of service prior to coverage. Enquired about the effective date rep said that the member effective from 10/01/1994 till 02/01/2011. She said no other plan coverage for the member. No other insurance coverage available in our database. Hence need to the contact the member for correct insurance information. Claim# and Ref#.

14.Claim denied for procedure code is within the global period

Need to check the denial date. Need to check to which procedure code is this procedure got denied as within global period. Need to check in internet whether it is a global charge and ask the rep what can be done for payment of the procedure code. If there is a modifier then need ask them to reprocess or else should ask rep whether we can rebill a corrected claim with a modifier. Need to check the time frame for submission of the corrected claim. Need to ask for fax# if available to submit a corrected claim. Claim# and Ref#.

Notes Format

For dos 06/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the procedure code is denied global with primary procedure code. Rep said that the claim denied with another procedure code on the same claim which is 71101. Told her that we do have added a modifier to the procedure code, Rep said that they do not have a modifier and asked to resubmit a corrected claim with an appropriate modifier. Enquired whether we can fax the corrected claim. Rep suggested faxing the corrected claim to fax# 345-234-6789 attn: Claims. Claim# and Ref#.

15.Claim denied Duplicate

Claim denial date. Need to ask rep about the original status of the claim. Claim# and ref#.

Notes Format

For dos 06/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating it is duplicate of previously processed claim. Rep sd that the original claim was paid on 06/25/2011 for an Alld amt $255.00, Pd amt $200.00, Copay $55.00, Paid thru chk# 456732145. It is a single check. Verified pay to address to be the same as our database. Claim# and Ref#.

16.Claim denied claim covered as per COB information Claim denial date. Need to check effective date and enquire whether they are secondary or primary for member. If they are secondary need to enquire about the primary insurance information. If they do not have any information we need to check in our database whether there is any other insurance information.

No insurance information need to contact the patient. Notes Format For dos 06/01/2011, Called UHC @ 877-842-3410 spoke with Gina said that the claim denied on 07/01/2011 stating that the member claim is covered by another payer. Verified eligibility and found member is effective from 01/01/2011 till date as secondary. She said that the member has medicare as primary. Hence need to resubmit the claim to primary Medicare. Claim# and Ref#.

17.Claim denied for need of medical necessity Check when the claim was denied? What kind of medical necessity information they need? Whether they need it from the patient or from provider? Have they sent any request letter regarding this and when they sent it? Procedure to send the medical necessity information? Claim# and Ref#

Notes Format For dos 01/01/2011, Called BCBS @ 835-563-3112 spoke with Krystal said that the claim dnd on 02/06/2011 stating need of medical necessity information. She said that they need history information from the patient. Rep said that they do have sent request letter for the patient on 03/04/2011 and they have not received any information as of yet. Claim# 1234567654. Ref# 23467555.

18.Claim denied for Need to primary EOB Check when the claim was denied? Need to check whether they are primary or secondary? Check whether we do have sent primary eob with the claim. If we sent need to ask them to check or if they are primary should tell rep that they are primary and ask to reprocess? Procedure to send the additional information? Claim# and Ref#

Notes Format For dos 01/01/2011, Called BCBS @ 835-563-3112 spoke with Krystal said that the claim dnd on 02/06/2011 stating need of primary eob info. Checked and found that we do have sent primary eob. Hence explained to her that we do have submitted the claim with primary eob, Rep sd that they have not received eob, She suggested to fax the eob to fax# 678-960-6789 attn: Reconsideration. Claim# 1234567654. Ref# 23467555.

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