1.

Claim is SET TO PAY:

DOS 11/06/2023 as per review found the claim was submitted on 11/10/2023 and no
response received yet, called payer UHC @ 877-842-3210, and spoke with JULIE stated that
the claim was received on 11/12/2023 and processed on 11/14/2023 and it is approved to
pay, also rep confirmed that there is no denial on this claim. Rep said allowed $75.00 and
set to pay $50.00 with pt resp Copay $25. Rep said the normal processing time is 30
business days from the received date so I verified the reason for the delay in processing rep
said that there is no specific reason it is just due to backlog anyhow they will issue the
payment soon, rep confirmed that payment will be out within a maximum of 15 business
days from today. Therefore, please allow some more days to receive the payment.
Claim#12345 and Call reference# JULIE12212023. Thank you.

Set to Pay, End Action:

The claim was received and exceeded the normal processing time then ask the rep the
reason for the delay in processing.

2. Claim Paid:

DOS 07/10/2023 as per review found the claim with billed $150.00 was submitted on
07/16/2023 and no response received yet, called payer UHC @ 877-842-3210 spoke with
SANDY stated that the claim was received on 07/25/2023 and processed on 08/01/2023.
The claim was paid on 08/05/2023. Allowed $100.00 and paid $75.00 with patient
responsibility Copay $25.00. The claim was paid through paper check# 12345678 under bulk
$1000.00, check issued on 08/06/2023, and cashed on 08/29/2023. Verified the check paid
to which address, the rep said it was issued to PO BOX 54032 Belfast Maine 78542.
Requested the denied EOB through fax and it will receive within a day. Therefore, please
wait for eob, once the eob is received through fax then send it for posting. Claim# A213456.
Call reference# SANDY12052020. Thank you.

Claim Paid, End Action:

1. If the claim is paid through a paper check and the paid date is more than 30 days then
request the cash date.

2. If the rep doesn’t have a cash date, then request a check trace

3. If the claim paid date was more than 30 days, then request the EOB through fax or mailing
address.

3. Claim denied for NO AUTHORIZATION:

(Claim Adjustment Reason Codes: 197)

DOS 07/26/2023 as per review found the claim with billed $1500.00 was submitted on
07/30/2023 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 08/08/2023 and denied on 08/16/2023 stating
no authorization on file. I checked the system unable to find the authorization# also verified
the claim image no authorization was found in box#23, also checked the documents folder
unable to find the authorization documents. So requested to rep to find any hospital claim
was received on this DOS, rep checked and said no hospital claim was found on this DOS. So
verified the possibility of retro authorization rep said retro authorization is not possible. So
requested the appeal information, the rep said the appeal address is PO BOX 30432 SALT
LAKE CITY UT 84130-0432, and the appeal timely filing limit is 365 days from the date of
denial. I verified the billing summary no payment was found previously on this code.
Therefore, sending an appeal with medical records. Claim# 98745 and Call reference# 8578.
Thank you.

Authorization: The provider needs to get from the insurance

 It is the process of obtaining prior approval before providing a certain service to the
patient.
2 types:

 a) Prior/Pre-authorization: Getting Approval BEFORE service

 b) Retro authorization: Getting Approval AFTER service.
No Authorization, End Action:

 1. If Auth# is not available and Retro Auth# not possible then send an appeal with
complete medical records to show the medical necessity
 2. If the payer still denies then write off the claim.
4. Co-ordination of benefits update needed/Additional information requested from the
patient:

(Adjustment reason code: CO 22)

DOS 04/02/2023 as per review found the claim with billed $1500.00 was submitted on
04/10/2023 and no response received yet, called payer UHC @ 877-842-3210 spoke with
SANDY stated that the claim was received on 04/20/2023 and denied on 04/25/2023 stating
additional information requested from the patient. Verified what information was needed
from the patient, Rep said they need co-ordination of benefits update, so I verified any
letter sent out to the patient regarding COB update, the rep checked and said the first letter
sent out to the patient on 05/08/2023, and the second letter sent on 06/08/2023 and no
response received so far. So, I requested to send 3rd letter rep accepted to send the last
letter, also the rep advised me to inform the member to call their member’s benefits
department at 877-852-4230 to update it. Rep said there is no time frame but asked to
update as soon as possible. Also, I requested the COB last updated date, the rep said it was
last updated on 02/08/2022 at that time UHC is primary and no other insurance was found.
Also, the rep said once the COB has been updated by the patient the claim will automatically
get processed, and the provider no need to call back to inform. Claim# XYZ5823 and Call
reference# SANDY12/05/2023. Thank you.
COB, End action:

 If the letter was sent to the patient has not crossed 30 days allow some more time.
 If the letter was sent has crossed 30 days, then bill the claim to the patient.
 If the claim is denied for COB update, then check the patient payment history if the
payment on nearby DOS is received from any other insurance as a primary then
check the eligibility of that insurance and bill the claim to that insurance.
5. Claim denied for MISSING/ABSENT REFERRAL:

(Adjustment reason code: 288)

DOS 04/02/2023 as per review found the claim with billed $1500.00 was submitted on
04/10/2023 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2023 and denied on 04/25/2023 stating
referral number is missing. Verified the patient plan type rep said the patient plan is HMO so
a referral is needed. Checked in system and claim form in box# 23 unable to find the referral
number. Requested to check hospital claim, the rep checked and said hospital claim was not
found. Therefore, requested the PCP (Primary care physician) name and phone number, rep
said PCP’s name was DONALD OBAMA and Phone# 800-586-9321. Rep provided corrected
claim mailing address is PO BOX 74088 ATLANTA GA 30374 and the timely filing limit is 120
days from the date of denial. Therefore, please resubmit the corrected claim with referral#.
Claim# UAS5823 and Call reference# SANDY09012023.

No Referral, End Action:

 Assign to client assistance to get the Referral from PCP

 PPO & EPO plan does not require a patient to visit a referring physician, so referral is
not required whereas in HMO & POS plan, it is necessary to visit a referring doctor,
so referral# is required.
6. Claim denied for patient policy terminated or Expenses incurred after coverage
terminated:

(Adjustment reason code: 27)

DOS 04/02/2020 as per review found the claim with billed $1500.00 was submitted on
04/10/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
SANDY stated that the claim was received on 04/20/2023 and denied on 04/25/2020 stating
Patient policy not active on this DOS. Verified the Patient policy effective date and term
date rep said the policy was effective from 02/22/2019 to 02/21/2020. Also checked in
billing summary/claim history unable to find claim payment for other DOS after 02/21/2020.
Also requested with the rep to find any other active policy on this DOS, rep checked and said
no active policy found. Requested the denied EOB through fax and it will receive within a
day. Also, I checked in system unbale to find other payer information. Therefore, need to
call the patient for an active policy if the patient doesn’t have any active policy, then the
claim needs to bill the patient. Claim# XYN5823 and Call reference# SANDY09082020. Thank
you.

Policy terminated, End action: Bill patient.

  Bill patient if no other active insurance is available.
 When other insurance is available 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 to
that insurance.
7. Claim denied for DUPLICATE:

(Adjustment reason code: 18)

DOS 04/02/2020 as per review found the claim with billed $1500.00 was submitted on
04/06/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
SANDY stated that the claim was received on 04/10/2020 and denied on 04/20/2020 stating
this is a duplicate claim. Asked the rep to find whether this claim was received as an original
claim or a corrected claim, the rep checked and said it was received as an original claim, so it
was denied as a duplicate. Verified the original claim status, rep said the original claim was
Paid it was received on 04/07/2020 and paid on 04/17/2020. Paid $800.00 with patient
responsibility Copay $30.00 paid through paper check for bulk check of $1000.00 under
check# 12345678 issued on 04/25/2020. Verified the check payable to the address found to
be the same as PO BOX 54032 BELFAST MAINE 78452. Verified the check cash date rep said
it was cashed on 05/15/2020. Requested both original and duplicate eob through fax back
system and it will receive within a day. I checked the system and found we billed the claim
twice with the same information. Therefore, sending the duplicate claim for adjustment.
Original claim# ABC1234 and Duplicate claim# XYB5678. Call reference# SANDY09162020.
Thank you.

Duplicate, End Action:

 If two claims are submitted to insurance with the same claim information.
 AR caller needs to call insurance and verify whether the claim was received with the
same information or not.
 If the same claim was submitted twice need to write off/adjust the duplicate claim.
8. Claim denied for INCLUSIVE | GLOBAL | BUNDLED DENIAL:

(Adjustment reason code: 97)

DOS 04/02/2020 as per review found the claim with billed $1500.00 was submitted on
04/10/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2020 and denied on 04/25/2020 stating
claim (CPT 78452) was bundled with another claim. Asked the rep to which CPT code it was
bundled with; the rep said the CPT 78452 was bundled with CPT code 84321 on different
DOS 04/01/2020. The verified global period rep said the global period is 10 days. The rep
suggested before sending an appeal asked to send a corrected claim first with the
appropriate modifier if the corrected claim is denied then send an appeal. Rep provided
corrected claim mailing address is PO BOX 740805 ATLANTA GA 30374 and the timely filing
limit is 120 days from the date of denial. I verified the billing summary no payment was
found previously on this code. Therefore, send this to the coding team to send a corrected
claim with the appropriate modifier. Claim# P458 and Call reference# SANDY10102020.
Thank you.
Bundled, End action:

 Send to the coding team to Check the NCCI edit between procedures.
 If the coding team responded with the correct modifier, then send a corrected claim
to insurance.
 If the coding team responded as the coding is correct, then call the insurance and ask
them to reprocess the claim. if they deny then send an appeal to insurance.
Globally Inclusive End action:

 When the DOS is between the Global period range then it should be written off but
there is a possibility to separate out the procedure with main surgery by adding
modifier as well, so assign it to the coding team for clarification.
9. Claim denied for PRE-EXISTING CONDITION:

(Adjustment reason code: 51)

DOS 04/10/2020 as per review found the claim with billed $1500.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2020 and denied on 04/25/2020 stating
a pre-existing condition are not covered. Verified about waiting period rep said the waiting
period is 15 days, the start and end date of the waiting period is 04/01/2020 to 04/15/2020.
Requested to send a letter to the patient, the rep said they have already sent a letter to the
patient. Verified how many letters they have sent to the patient, the rep said they have sent
all 3 letters, the last letter was sent on 05/30/2020, so they were unable to send another
letter. Requested the denied EOB through fax and it will receive within a day. I verified the
billing summary no payment was found on any dos lies between this period. Therefore,
need to bill the patient. Claim# P458. Call reference# SANDY10152020. Thank you.

Pre-Existing condition, End action:

 If DOS lies within the waiting period, then bill the claim to the patient.
 If DOS does not lie between the waiting period, then ask the rep to reprocess.
 Do not bill the claim to a secondary or consecutive payer since they are not going to
process the claim.
10. Claim denied for CPT Inconsistent with Diagnosis or Billed CPT is not valid for the
diagnosis or vice versa:
(Adjustment reason code: 11)
DOS 04/10/2020 as per review found the claim with billed $1500.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/202 and denied on 04/25/2020 stating
claim was denied for the CPT code is inconsistent with DX code. Verified about the diagnosis
code rep given we have billed z94.0, also checked claim form found the same Dx code.
Checked in billing summary no payment found previously with this CPT and Dx code
combination. The rep suggested to send a corrected claim with the appropriate Dx code,
and the corrected claim mailing address is PO BOX 740805 ATLANTA GA 30374, and the
timely filing limit is 120 days from the date of denial. Therefore, sending this to the coding
team to verify the CPT and Dx combination. Claim# 8324 and Call reference# 123. Thank
you.

CPT & DX inconsistent, Action:

 If you found payment on any previous dos with this CPT & Dx code combination, give
that DOS to rep to verify and ask to reprocess.
 If there is no payment found previously, then assign to the coding team to review
and provide the correct Dx code, and once a response is received with the correct Dx
code then send a corrected claim.
 If the coding team states, the diagnosis code and CPT code combination are correct
then send an appeal to insurance.
 Work as same for:
 CPT code is inconsistent with the patient’s age, CPT code is inconsistent with the
patient’s gender (here CPT code needs to change).
 Diagnosis code is inconsistent with patient’s gender, Diagnosis code is inconsistent
with patient’s age (here Dx code needs to change).
11. Claim denied for Maximum benefits have been met or Maximum Benefit Exhausted:

(Adjustment reason code: 119)

DOS 04/10/2020 as per review found the claim with billed $1500.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2020 and denied on 04/25/2020 stating
maximum benefits has been met. Verified about maximum benefits in terms of dollar or
visit rep said max benefits reached in terms of visits. Asked rep how many visits rep said 12
visits were allowed per calendar year and the max visits were met on DOS 01/03/2020.
Requested the eob through fax and it will receive in 24 hours. Claim# 558. Call reference#
SANDY10152020. Thank you.

Maximum benefits met, End action:

 If a patient has met the allowed dollar amount or visits excluding this claim, then the
claim must be billed to the secondary payer/consecutive payer or patient.
 If no other payer is active or available on DOS, then bill the claim to the patient.
12. Claim processed as Primary Paid Maximum OR Primary paid more than the secondary
allowed amount:

(Adjustment reason code: 23)

DOS 04/10/2020 as per review found the claim with billed $100.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2020 and denied on 04/25/2020 stating
primary paid more than secondary allowed. Verified the secondary allowed amount rep
said secondary allowed $75.00 and checked the primary eob found the primary already paid
$70.00, so the $5.00 only secondary paid which was already posted in software and the
outstanding $15.00 is provider write-off. Therefore, sending this to the posting team to
adjust. Claim# WEC896 and Call reference# 4567. Thank you.
Primary Paid Maximum End action:

 If the primary paid amount is more than or equals to the secondary allowed amount,
then write off the charge.
 If the primary paid amount is less than the secondary allowed amount, then it’s
secondary insurance’s responsibility to pay the remaining amount. Ask the rep to
reprocess.
13. Claim denied for NON-COVERED SERVICE:

(Adjustment reason code: 96)

DOS 04/10/2020 as per review found the claim with billed $100.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2020 and denied on 04/25/2020 stating
non covered under the patient plan, verified what is non-covered in the patient plan, the
rep said the patient plan doesn’t cover out of network benefits. Requested what plan the
patient has, rep said the patient plan is HMO. I checked the billing summary no payment
was found previously on this patient’s account. Therefore, requested the EOB through fax
and it will receive within 24 hrs. Claim# 8979. Call reference# 55888. Thank you.

NON-COVERED SERVICE, as per patient plan End Action: Bill the patient.
 Check billing/claims history to whether this same CPT code was paid already if found
give that DOS to the rep and get clarification on how it was paid and ask to send the
current claim for reprocessing.
 If no previous dos were paid on this code, then send it to the coding team to verify
the coding.
 If the coding team says the coding is already correct, then send an appeal.
 If the appeal is denied, then request the EOB through fax or mail.
 This can be billed to a secondary or consecutive payer.
 If no other payer is found, then bill the patient.
If code denied as non-covered as per patient plan type, End Action:

 HMO and EPO plan doesn’t cover OON therefore the denial is correct.
 PPO or POS cover OON then ask the rep to send the claim back for reprocessing.
 If there is a secondary payer on DOS, then bill the claim to secondary.
 If there is no secondary payer on DOS, then bill the patient.
Notes for Non covered under provider contract:
……stating non-covered as per provider contract, verified what is non-covered in provider
contract rep said the provider is not eligible to bill this service (CPT). Checked billing
summary no payment found previously on this CPT code under our provider. Requested
appeal address PO BOX 30559 ATLANTA GA 3074 and time frame is 90 days. Claim# 8979.
Call reference# 55888. Thank you.

As per provider contract, End action: Write-off or adjustment

  Check billing/claims history whether this same CPT code was paid already if found
give that DOS to the rep and get clarification on how it was paid and ask to send the
current claim for reprocessing.
 If no previous dos were paid on this code, then send to the coding team to verify the
coding.
 If the coding team says the coding is already correct, then send an appeal.
 If the appeal is denied, then request the EOB through fax or mail.
 Once you received the EOB then send it to be posting and adjust the claim
14. Claim denied for Medically not necessity:

(Adjustment reason code: 50)

DOS 04/10/2020 as per review found the claim with billed $100.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received on 04/20/2020 and denied on 04/25/2020 stating
medically not a necessity. Checked billing summary no payment was found previously on
this diagnosis code and CPT code combination. Therefore, requested a corrected claim
address PO BOX 31362 SALT LAKE CITY UT 30895 and the time frame is 120 days from the
denial date. Also requested appeal address PO BOX 30559 ATLANTA GA 33589 and time
frame is 90 days from denial date. Therefore, sending this to the coding team for review.
Claim# 99966. Call reference# 89997. Thank you.

Medically not necessity End action:

 Send to the coding team to review and provide the correct dx code and once a
response is received with correct dx details then send the corrected claim to
insurance by updating the correct dx code.
 If the coding team states that the dx code is correct then send an appeal to
insurance.
15. Claim denied for TIMELY FILING LIMIT (TFL) EXPIRED:

(Adjustment reason code: 29)

DOS 04/10/2020 as per review found the claim with billed $100.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was denied on 06/25/2020 stating claim received after the
timely filing limit. Rep said the claim was *received on 06/15/2020 and the normal TFL is 60
days from DOS. Rep asked to send an appeal with proof of timely (POTFL) also provided
appeal address is PO BOX 30559 ATLANTA GA 33589 and the time frame is 90 days from the
denial date. Therefore, need assistance to send an appeal with POTFL. Claim# 22255. Call
reference# 6633. Thank you.

TIMELY FILING LIMIT (TFL) EXPIRED, End Action:

 If the claim was billed within TFL then ask the rep to reprocess.
 If a claim was filed after TFL, as mentioned in the notes please send an appeal with
any POTFL.
  If the claim was initially billed to different insurance within TFL, we can use that
payer EOB as proof of timely.
16. Claim processed towards OFFSET:

What is Offset?

Sometimes payer might mistakenly have paid or overpaid to the provider also provider has
not responded /refund the overpaid amount to the payer then the payer will adjust that
payment from future claims of that particular provider. Adjustment can be taken from any
patient under that provider.

DOS 04/10/2020 as per review found the claim with billed $100.00 was submitted on
04/15/2020 and no response received yet, called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received 04/15/2020 processed on 04/25/2020 stating
claim processed towards Offset. Requested the Allowed is $60.00 and the patient’s
responsibility is a co-pay of $30.00. Requested to which patient account# it was Offset rep
said the patient account is 666633, the Offset DOS is 11/02/2019 and the CPT code is 83214,
also rep gave the overpaid check# 55777 issued on 11/20/20219 and cashed on 12/07/2019.
Requested the eob through fax rep said it will receive within a day. Claim# 12213223. Call
reference# 002. Thank you.

Another possible reply from the rep stated due to HIPPA violence unable to disclose other
patient details until or unless you verify that particular patient information So I cannot
provide you the payment or patient details. In this case, just ask the rep “what is that
patient account#” and document your notes as “rep refused to provide other patient
payment details due to HIPPA violence but provided that patient account# is 1234567”.

Offset, End Action:

 If the payer previously overpaid or paid incorrectly then the claim needs to send for
posting to close the account.
17. Claim denied for Invalid place of service (POS):

(Adjustment reason code: 58)

DOS 04/10/2020 as per review found the claim with billed $100.00 was submitted on
04/15/2020 and no response received yet, Called payer UHC @ 877-842-3210 spoke with
Sandy stated that the claim was received 04/15/2020 processed on 04/25/2020 stating
invalid POS. Requested the rep to provider correct POS, rep doesn’t have correct POS so
asked the rep to check any hospital claim received on this DOS, the rep said one hospital
claim received on this DOS and therefore requested the POS billed in that hospital claim rep
said the POS in hospital claim is 21. Also, the corrected claim address is PO BOX 31362 SALT
LAKE CITY UT 30895, and the time frame is 120 days from the denial date. Need assistance
to change the POS, once changed corrected claim need to submit. Claim# 667799. Call
reference# 88775. Thank you.

Invalid place of service, End action:

 If the rep provides a correct place of service, then update it and send a corrected
claim.
 If the rep does not provide then assign the claim to the coding team to review and
provide a correct place of service
 When the response is received as coding is correct again call insurance and try to
reprocess the claim if the rep disagrees then ask for appeal details and send an
appeal to insurance.