Denial Management III

Claim denied as Subscriber Only Covered:

Check in the system whether the patient was paid earlied by the some insurance.

If the insurance had paid inform the patient earlier inform the rep and send the claim for reprocess.

Claim Denied as Patient was not assigned to that Dental Office:

Check in the system whether the insurance had earlier paid for dental office.

If they paid inform the rep and send the claim for reprocessing.

If had not paid. Send it for client investigation.

Claim pending foe Primary EOB:

Check in your systems whether the claim was billed to the primary and there is a payment made.

If the claim is not billed to the primary find the primary insurance and bill it.

Get the mailing address for sending the claim with primary EOB.

If possible get a FAX number and Attn. And send the fax.

Get the filing lime.

Claim Approved for Payment check not released:

Get the processed date.

Get the allowed amount, amount approved to pay and the patient's responsibility.

Get the date when the payment would be released.

Whether check payment or electronic fund transfer.

Claim denied in Error and Sent for Reprocessing:

Get the denied date.

Get the reason for denial.

Get the date when the claim will be processed.

Claim and reference number.

Claim pending for Detailed Narratives:

Check in the system whether the requested information had been sent earlier.

If it had sent and not received by the insurance company.

Get the mailing address or FAX# to send the requested information.

Get the time limit to send the requested information.

Claim Denied as Patient has met the Maximum:

Ask the rep whats the maximum benefits tat the patient has for the calendar year or ow many visit the patient is entitled per calendar year. (E.g.: Routine Check ups/ calendar year).

ASk the rep when was the last DOS that the patient maxed out the benefits / visit,

Immediately cross verify the information in your software that the information is correct.

If there is no DOS for the PT for the provider ask the rep if the DOS is for the provider you are billing for.

If the rep says yes tell her that the information is wrong and ask her to send the claim for reprocess.

If its difference provider check if the PT has other insurance / bill the PT.

Claim Pending for Full Time Student Status:

Ask the rep whether a request was sent to the patient.

If so how many request was sent to the patient.

Ask whether the patient responded beck for the request.

If the patient had responded back for the request.

If the patient had not responded for the request , ask the rep how long the patient has time to respond back.

If the project has patient calling access call the patient and inform the patient about the status of the claim. If not bill to patient.

Claim number, received and processed date needed.

Claim Denied for Provider Details (W-9 form, License number, Malpractice notes etc):

Get the denied date received date.

Get the FAX number or the Mailing Address.

Send the information in suitable way.

Claim Denied as Procedure Billed as non covered under Patient's Plan:

If it is patient's Plan, check in your system for history claims whether same procedure code was paid by the same insurance earlier.

If there is any payment for the same procedure earlied, quote the DOS to the rep and try to send the claim for reproxcessed.

If there are no DOS, check whether the patient has any other insurance, if not bill to patient.

Claim Denied for Medical Necessity:

Ask the rep whether we can appeal with complete dental records.

Get the mailing address for Appeals.

Get the time limit to send the appeals.

Claim applied towards Capitation:

Get the date when it was applied towards capitation.

How much was applied towards capitation.

Claim denied for Untimely Filing:

Get the received date of the claim.

Ask for the filing limit of the carrier.

Cross verify whether they received the claim beyond the filing limit.

If the received date is within they received the claim beyond the filing limit.

If it was the received date is within the filing limit ask the rep to send the claim for reprocess.

If the received date is beyond the filing limit and if the claim was billed at least one within the filing limit and never reached the insurance. Ask the rep whether it can refiled with an appeal and proof of timely filing.

If it was not billed at least once during the filing limit the claim needs to be adjusted (only with approval of the client).

Ask the rep what proofs the insurance requires for proof of timely filing.

Get the appeals mailing address and filing limit for appeals. If possible get the FAX number and Attn.

Claim denied for Age Limitation:

Ask the rep the age range for the procedure code billed.

Cross verify with pt's age in the demographics if it is in compliance inform the rep and send the clim for reprocessing.

If it is not in compliance update the notes and it to coding team or to the client.