Denial scenarios PPT Dental Billi g.pptx

Dental

1. US Healthcare Denial Scenarios

2. Denial Scenarios Claim Not In System Claim Denied For Exceeding the Filing Limit Insurance Not Able To Identify Patient Claim In Process No Coverage For Date Of Service Claim Paid To The Patient Payment Applied To Deductible Claim Denied As A Duplicate Claim Denied As Maximum Benefits Met Claim Denied As The Diagnosis Code Being Inconsistent With The Procedure Code Capitated Payment Claim Denied For No Referral Or Prior Authorization Claim Denied As Provider Is Non-Par Claim Denied Due To Incorrect Modifier Claim Denied For Primary Explanation Of Benefits Claim Denied For Non-covered Service Procedure Not Payable Claim Denied As Mutually Inclusive Claim Offset Claim Denied As Pre-Existing Condition Claim Paid / Claim Paid To Wrong Address Claim Denied For Medical Records

3. Not Active Active Availabl e Not Available Availabl e No Yes Not Availa ble C C l l a a i i m m N N o o t t I I n n S S y y s s t t e e m m Verify Patient Eligibility § Verify Effective Date of Policy § Verify Status of Coverage Get Claim Mailing Address, Phone No., Fax No., Filing Limit (For - In- Network and Out of Network provider) & Processing time If Claim filed within the Filing Limit If within the time frame, Mail / Fax the claim to the Insurance. If Filing Limit exceeded, appropriate action code is marked on the account for client’s action Mail / Fax the claim with the proof C C h h e e c c k k f f o o r r o o t t h h e e r r I I n n s s u u r r a a n n c c e e C C o o v v e e r r a a g g e e w w i i t t h h t t h h e e R R e e p p r r e e s s e e n n t t a a t t i i v v e e Get Insurance Name, Address, Phone No., Id No., other Insurance Information. V V e e r r i i f f y y f f o o r r o o t t h h e e r r I I n n s s u u r r a a n n c c e e d d e e t t a a i i l l s s i i n n t t h h e e s s y y s s t t e e m m Call the available Insurance to verify eligibility Get Claim Mailing Address, Phone No., Fax No., Filing Limit & Processing time Bill the claim to the Insurance Call Patient, get the required Insurance Information

4. Within the Not Within the Timely Filing Limit Timely Filing Limit Yes Yes No With Appeal C C l l a a i i m m D D e e n n i i e e d d f f o o r r E E x x c c e e e e d d i i n n g g t t h h e e F F i i l l i i n n g g L L i i m m i i t t Get Denial Date Verify with Insuranc e, when the claim was received for the first time & get the Filing Limit for submission Update the same with the Insurance and get the claim reprocessed Get the claim Ref. No and reprocessing time for further follow up Mail / Fax the claim with the Proof (System / NEIC) Get Appeal Mailing Address, Phone No., Fax NO., & Processing Time for further follow up Need to write off/ ADJ the claim V V e e r r i i f f y y f f o o r r t t h h e e b b i i l l l l e e d d s s t t a a t t u u s s i i n n t t h h e e B B i i l l l l i i n n g g s s y y s s t t e e m m , , i i f f f f i i l l e e d d e e a a r r l l i i e e r r

5. Available No t Available Available Not Available Not Available Available Not Eligible Eligible Eligible I I n n s s u u r r a a n n c c e e N N o o t t A A b b l l e e T T o o I I d d e e n n t t i i f f y y P P a a t t i i e e n n t t Ensure if reached the right Insurance Request for SSN Search (If different from ID#) Request for Name / Address / DOB Search Check any other Insurance details available in the Billing Software Get the correct ID No. of th e patient and the eligibility details Get the status for date of Service in question Appropriate actions taken according to the status Call patient and find out the required details Call Insurance to check if patient is eligible Get Claim Mailing Address, Phone No., Fax No. & Processing Time Mail / Fax to the Insurance accordingly

6. C C l l a a i i m m P P a a i i d d T T o o t t h h e e P P a a t t i i e e n n t t Get the date on which the Claim was processed Get the reason w hy the Claim was paid to the patient Need to bill patient Get any other Payment details available (amount paid etc)

7. Same Different Claim Claim Need to write off the claim Possible cases § Same provider rendering two different services on the same day § Two different providers rendering different services on the same day. Get the denial date and status of the Original Claim C C l l a a i i m m D D e e n n i i e e d d A A s s D D u u p p l l i i c c a a t t e e Verify § § Billed Amount § Provider’s Name Procedure Code Get the appeal address and the time frame within which the claim has to be appealed ( with supporting medical document if required) Appeal and Follow up on the appropriate day

8. Received Not Claim Denied for Medical Records Get Denial Date Check if medical records were sent earlier. Request Medical records to respective provider, When responded need to send the medical records to payer Update the Insurance with the appropriate details and get the Claim reprocessed. Get the reprocessing time and Claim Ref. No. for further follow up Follow up on the Claim.

9. Thank You