Appeals
Last Level of Appeal Denied, Appeals Exhausted.
what action should be taken?
Open case to patient Billing Notification (PBN) cc: Appeals Exhausted (AE)
Waiting Cases
Place case on a 1 day wait ONLY if:
Insurance company is closed due to a holiday
Hold time exceeded 60 minutes for initially attempting to reach a representative
Left detailed voicemail
What is Tempus fax number ?
216-502-3838
How do you identify the current case status of the case?
by reviewing the journal notes documented in both PAS and HARP.
Case Review is unacceptable answer. Emphasize
What does NARA stands for?
No Additional Records Available
Appeal write-off requests:
(What to do)
COMMERCIAL
Open the Patient Billing Notification (PBN) worklist with condition code write-off review (WOR)
Claim Follow-Up Process :
If it is determined no follow-up is necessary due to other actions taken:
What action should be taken?
Select Claim Follow-Up Calls event task
Status complete
Condition code Reviewed – No Call
Add a journal entry explaining why no call is needed on the case
📋
What does the clipboard emoji represent?
Medical records are on file
Scenario:
W-9 Requested
What action should be taken?
Global Team: Select the Insurance Staff Follow-Up work list, status (open), "W-9 Needed" condition code".
👍
What does the thumbs-up emoji represent?
Patient Consent Received
Claim Paid, Payment Sent to Provider :
If check date > 14 days prior to current date, what should be the action taken.
Open case onto the Receipt Staff Follow-Up (RSFU) event/task with condition code “Insurance Payment Not Posted” (IPNP) for the receipts team to research the payment.
Common Claim/Line Level Denial Codes
Denial Reasons
CO-96 – Non-covered
CO-242 – Out of network
CO-50 – Not Medically Necessary
CO-252 – Attachment Needed (Med Recs)
CO-55 – Experimental/Investigational (E&I)
CO-197 – No Prior Authorization
CO-39 – Services Denied at Time of Request (PA denial before claim submission)
CO-18 – Duplicate Claim
CO-29 – Claim Timely Filing
What does PFFS mean?
private fee for service
Claim denied for timely filing.
COMPLETE PROCESS
Select the Insurance Staff Follow-Up event/task, status (Open), condition code “Claim Timely Filing Denial”. Or CC Unable to resolve (UR) would be also appropriate.
Detail in the journal entry that insurance has denied claim for timely filing, include any contact information if given.
If case is open in MRNCLI and MRNC calls, do we still need to follow up?
Yes
Provide the denial reasons of the following:
CO-49
CO-50
CO-55
CO-56
CO-39
CO-49 – Non-covered or out of network
CO-50 – Not Medically Necessary
CO-55 – E&I
CO-56 – Unproven
CO-39 – No Prior Authorization
If the claim has been forwarded to the Medical Group or IPA, what is the process for the Global Team?
Global Team - Select Insurance Staff Follow-Up work list, status (Open), with condition code "Update Insurance/DMG/IPA".
What information needs to be obtained and documented if the representative states that there is no supervisor or manager available, that the supervisor or manager is unavailable, or abruptly states that the claim will be processed in order to end the call?
The name of the representative
The time of the call
Any other pertinent information (other necessary information)
Patient's insurance plan inactive for Date of Service
Select the Insurance Staff Follow-up Event/Task, status (Open) with condition code "Need Insurance Information" (GO) or "Subscriber Not Found".
Detail in the journal entry that patient's insurance terminated prior to DOS and to obtain the correct information.
ANSI Code: 16
Description
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.
Appeal Not on File
- If correct and timely filing has passed:
- If incorrect and timely filing has passed:
What action should be taken?
Do not deny the appeal. Complete the appeal follow-up call worklist with condition code “Appeal not received” (ANR) and open the Appeal Staff Follow-up (APSFU) worklist with CC: Appeal not on file (ANOF) for further review.
Deny the appeal and open the Appeal Staff Follow-up (APSFU) worklist with CC: Appeal not on file (ANOF) for further review.
At Claim Level, If the insurance will not process the claim after the NARA letter is sent and received, open Client Write-Off Manager Review with condition code Insurance Requesting Addtl Records after NARA (IRARANAR). You will need to open the case to PBN.
False.
You will no longer open the case to PBN.
What are the items that need to be verified if the case is an appeal?
Verify that the denial date was entered correctly.
Verify that the primary denial reason was selected correctly.
If the claim number is known, make sure that it has been entered into the claim number field.
Confirm that the number of appeals available and who can submit the appeal, (Member or Provider) are correct.
Check the number of days available to submit the appeal and confirm that the correct appeal deadline date is displayed.
If medical records are required and have not yet been requested, initiate the process by following the steps outlined in the Medical Records SOP.
If patient consent is required to submit a provider appeal, verify that the signed form has been received from the patient. If the consent form has not been received, initiate the process by following the steps outlined in the Patient Consent Appeal SOP.
Verify that the appropriate appeal address was entered or selected. (This address may vary by appeal level or submitter.)
BC/BS or Anthem claim returned instructing us to bill the local BC/BS or Anthem carrier or plan or to submit the claim to the BC/BS or Anthem plan in the same state where specimen was drawn and/or referring physician is located
Select the Claim Follow-up Calls Event/Task, status (Complete) with condition code “Claim Not Received”.
Detail in journal entry any claim mailing information listed in the correspondence including the name and claim mailing address of the specific BC/BS or Anthem plan where the claim should be submitted.
Select the Insurance Staff Follow-Up Event/Task, status (Open) with condition code "Resend Claim".
Detail the following in the journal entry based on the information provided in the correspondence/call:
Note the claim was returned instructing us to bill the correct carrier (list any details,
i.e. name of correct carrier, claim mailing address.
b) Note the claim was returned instructing us to bill the correct carrier, but no additional insurance information was provided.
What is the Denial code for invalid place of service
CO - 5