Recent Updates
What is the process for faxed upheld letters?
If the payer will fax the upheld letter, document and defer 1 week after each call (up to 3 calls). If the letter is still not received after the 3rd defer period, adjust the claim.
During claim navigation, how do you submit a Corrected Claim (CC)?
Right-click the CPT → Claim Info Edit. To resend the corrected claim, right-click the CPT again → Charge Correct.
Payer says "Claim Not on File," but Epic shows Accepted. What should you do next?
Verify claim status, mailing address/Payer ID, and timely filing limit via payer portal or call, then resubmit per payer instructions.
A claim denied with OA-18 (Exact Duplicate). Epic shows the original claim was already paid for the same CPT and DOS. What should you do?
Route the claim to Coding Review Requested to verify whether a modifier is needed because the original claim has already been paid.
What mandatory documents must be attached when submitting an appeal through the web portal for an authorization denial?
Duly letter head
Medical Records
Payor specific appeal if any
Auth letter if available
Reimbursement policy if available
What is the AR team's first step when handling an MSP issue?
Review MSP in Epic and identify the correct MSP code because the claim must be corrected before resubmission.
Where can we locate MR in epic
Chart Tab
A claim denied for Medical Records Required (CO16/CO251/CO252). The records are available and valid in Epic. What should you do next?
Prepare the coversheet, attach the required records, and dispose the claim as Submit Medical Records because the requested documentation is available.
A claim is denied with CO-197 (Authorization/Precertification Missing). You review the referral lookup and find a valid authorization number that was not included on the claim. What should you do?
Contact the payer with the correct authorization number or if not reprocessed submit the corrected claim with valid auth
While sending a paper appeal, it is mandatory to attach a clean copy of the claim form.
TRUE
Can users make demographic changes on a claim?
No. Users should not make demographic changes because patient information must be updated through the appropriate workflow.
Where can we locate insurance card in Epic
Media Tab
Claims paid within 30 days should be dispositioned as Defer with the deferral reason Pending Payment
TRUE
A claim denied for invalid demographic information (N345/N382/N290). You compare the claim details with the patient's insurance card and find the information does not match. What should you do?
Transfer the claim to pre-Reg WQ 21504 because demographic changes must be completed by the Registration team only.
If claim initially denied for untimely filing and we identified that due to coding issue delayed filing claim to insurance company. What will be the correct adjustment code?
AC851
When should a courtesy appeal be submitted for commercial CO50 denials?
Denial exceeds $300 because only commercial CO50 denials under $300 are excluded.
In which tab should you check in Epic to verify whether the billed authorization is correct or not?
Click on Go To - Select Referral Lookup- Communication tab
A claim is denied with CO29 (Timely Filing). Your review shows the initial claim was submitted within the payer's timely filing limit. What should you do?
Call the payer and request reprocessing or appeal with Proof of Timely Filing (POTF) because the claim was submitted within the filing limit.
A claim denies with CO-23 (Primary Paid More Than Secondary Allowed Amount). You verify that the primary payer payment is greater than the secondary payer's allowed amount. What should you do?
Adjust the remaining balance with adjustment code AC700 because the primary payment exceeds the secondary allowed amount.
The claim was denied due to invalid authorization, and all appeal rights have been exhausted. Which adjustment code should be used?
AC519
Does having an ABN allow billing a Medicare Advantage patient?
No, because Medicare Advantage plans do not follow traditional ABN rules.
What are the correct steps to send paper claim ?
Add Note- Right Click on CPT- Demand Claims- Process- Accept
A claim denied with PR-96 (Non-Covered as per Patient Plan). Benefit verification confirms the service is not covered, but the patient has a secondary insurance on file. What should you do?
Submit the claim to the secondary payer with the primary payer EOB because a secondary insurance is available.
A claim denies with CO-50 (Not Medically Necessary). After reviewing the medical policy, you determine the diagnosis supports medical necessity. What should you do?
Contact the payer and request reprocessing because the diagnosis meets the medical necessity criteria /Submit an appeal
Claim denied for CO16 - claim lack information provided, Remark code - Operative report pending from provider and we do not have any MR for the same. What will be the correct disposition?
Coding review Request - Coding outside Records Request