Ask the rep how many times the procedure can be performed in a year.
Get the date hen the procedure was performed last.
Ask the rep whether the service was done with our provider or some other provider.
If it is with our provider cross verify the information with that in the system.
If it does not correlate inform the rep and send the claim for reprocess.
Claim denied as Primary paid Maximum:
Get the processed date.
Get the allowed amount for the procedure (secondary Insurance).
Ask the rep how much was allowed by the primary insurance.
Cross verify that the secondary insurance's allowed amount should be more or equal to the primary insurance's allowed amount.
If the secondary insurance allowed amount is less than the primary allowed amount inform the rep and send the claim for reprocess.
Else ask the rep whether we can bill to the patient.
Claim applied towards Deductible:
Get the claim processed date.
How much was allowed.
How much was applied towards the deductible.
If there is a balance left after they have applied towards the deductible ask the rep about it whether it's applied towards the ci-insurance or co-pay.
Ask whether it was applied towards the in network deductible or out of network deductible.
What is the total annual deductible for the patient and has patient satisfied the deductible.
Get the claim number, receive and processed date.
Claim Paid:
When was the claim paid.
How much was the allowed amount.
How much was paid.
Is there any patient responsibility.
Check number.
Is that a bulk check or a single check.
If bulk check what is the amount of the check.
Verify the pay to address.
Get the claim number, receive and processed date.
Patient identified as not insured.
Reconfirm with the rep that she is pulling out the patients record with the correct ID.
Search the patient by last and first name (Spell it out with phonetics).
Search by DOB.
Search by SSN (Social Security Number).
If the rep says still the patient cannot be identified.
Check in your system whether the same insurance has paid earlier.
It there is any payment made by the same insurance, give the claim number of that claim and try to pull the pt's record.
If there i no payment from the same insurance. Check if the patient has any other insurance / bill the to the patient.
Claim denied as Patient not eligible for the DOS (DOS precedes the policy effetive date, DOS service after the coverage period):
In both of these cases ask the rep the effective date and termination date of the policy.
Verify whether the DOS falls within the coverage period.
If the DOS falls within the coverage period ask the rep to send the claim for reprocess.
If the patient is not covered for the DOS.
CHeck in your system whether the patient has any other insurance.
If the patient has any other insurance call the insurance verify the eligibility, mailing address and filing limit.
Refile the claim to that insurance with denial from the former one.
If the patient does not have any other insurance flip the balance to the patient.
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