Follow Up Scenario
We are still waiting for Buckeye's response to the account on the status of an appeal. I have submitted a secure message today asking for an update ASAP. If I have not received a response within the next week, I'll follow up on the account again.
What action code would I put this claim in?
DOI
True or false: Populating the funding status in the recovery tab isn't necessary.
false
How will you receive your claims for follow up each week while in training?
Where can you locate your f/u template?
OneNote, week one, follow up template or sometimes the clients master spreadsheet
Called Cigna, spoke with Sarah. Called to determine if the first level appeal that was faxed on 1/5/2024 was received and determine the status of the appeal. Per Sarah, the appeal was not received. She asked what fax # it was sent to. I expressed that it was faxed to 1-888-656-2014. She expressed the appeal should have been faxed to 1-888-656-2015. She said there was still time to resend the appeal as we have until 5/15/2024 to appeal. Ref#215244; self-funded. When the appeal is not on file, what process do you follow?
DORC Process
You sent the claim to your trainer in the DORC action code status based off your f/u call stating that the appeal was not received and needed to be resubmitted to UHC via mail at
United Healthcare, Attn: Provider Appeals, P.O. Box 30559, Salt Lake City, UT 84130-0559. Your trainer has returned the claim/account to you approved to mail. What action code do you use to mail the appeal again?
DAC
Give three examples of what you would upload on the documents tab?
EOB, UB, Medical Records, Carrier docs, appeals
What should you ask if you call about the appeal/reconsideration and they state it wasn’t received. Give me three responses please.
confirm where the previous appeal/recon was sent is the correct address.
Ask what the preferred way to receive the appeal/recon is.
Get any fax numbers or addresses to submit appeal/recon to.
Who are you calling when you make a f/u call?
Carrier
We submitted our appeal to Humana and you called to check the status. You speak with rep Judy and she states that they have upheld the denial on your first level appeal. You have 60 days to submit a second level appeal. You're still within the timely filing guidelines and you complete a second level appeal. You have DORC'd this to your trainer and it has been approved to submit to Humana. You upload the second level appeal through Availity portal to Humana.
What action code would I put the claim in?
DSO2
Called Anthem Medicare Advantage 1-844-421-5662, spoke with Allie (CR# i-122789249) to get an update on the first level appeal. States they rec'd the appeal 6/23/24 and as of today there is no determination. I had rep transfer me to a supervisor to have review escalated. States to allow 7-14 business days for review. When calling back use claim #180891431400753 for reference. This account is self-funded.
What action code do I use for this claim?
DCE
What tab in Bridge would you locate the action code, collector, contract amount, reason for denial?
Recovery Info
What are some details you should have on your template when you make a call to a carrier? Give me three
Appeals address/fax number
Claim status
timely limits
denial letter if applicable
Verified account was __________ funded?
fully/self
Called Anthem to see if the appeal that was mailed on 11/24/2024 was received. Per rep, appeal was not on file. Rep stated on the call that the only option was to remail the appeal packet and the timely filing was 90 days from EOB denial. Rep verified address that the appeal was mailed to originally was correct. I notated the account with the information given to me by the rep. The next step/process is to send this in the DORC action code. Who are you DORCing this claim to?
Trainer
Called BCBS @ 844-421-5662. Spoke with Mara. I asked for the status of the RECONSIDERATION that was submitted 9/2/2024 pertaining to the claim denying Jcode. Per Mara, Auth was denied, Auth #191173108200870 denial on J code and reconsideration was upheld on 10/23 due to not sufficient med recs. Denial letter was unavailable. I asked if there was a second level appeal and what the timely filing was. She said it can be appealed, and we have 180 days from determination of the first level which was only 30 days ago. She said appeals can be mailed, faxed, or submitted through the portal. I confirmed the information for all 3. Ref:1252346; Fully funded.
What action code would I put this claim in?
DAN
Where do you go when you want to look up an account in Bridge?
Recovery Search
What carrier information should we ask when we make a call. Give me three please.
Phone number
Representatives name
call reference number
Where can you locate the information to populate your Things you need to know for a call template?
Bridge Recovery screen or UB
Called BCBS @ 844-421-5662. Spoke with Tom. I asked for the status of the appeal that was submitted 9/5/2025 pertaining to the claim denying Jcode. Per Mara, Auth was denied, Auth #18765418200870 denial on J code and appeal was upheld on 12/23 due to not sufficient med recs. Denial letter was unavailable. I asked if there was a second level appeal and what the timely filing was. She said it can be appealed, and we have 180 days from determination of the first level which was only 30 days ago. She said appeals can be mailed, faxed, or submitted through the portal. I confirmed the information for all 3. Ref:1252346; Fully funded.
What action code would I put this claim in?
DSA
Called Humana for the FIRST time, spoke with Mike, per Mike denial was partially overturned on the appeal and he shows all days approved except 9/16/24 which remains denied for medical necessity. However, prior to calling, I checked Availity, and per Availity portal, the approval letter stated ALL dates of service were now approved. I expressed this to Mike, therefore now Mike is sending it back for review, allow 30 to days, CRF # 2101254225000; self-funded - - - What action code would I use for this call note?
DFP1
Reason codes are important because it give the client a snap shot of what?
claim denials and what areas they need to improve on
If you call for the follow up on an appeal/reconsideration and they state that it was denied, what are some things you should ask? Give me three.
when was it received
when and why it was denied
is there level of appeal
timely filing for second level of appeal
Name five things that you need to know when making a f/u call?
“This call is being recorded for quality and training purposes”
Follow Up call
Patient Name (line 8):
Patient DOB (line 10):
Patient # (Account Number) (line 3A):
Hospitals Name (line 1):
Payors Name (line 50)
Tax ID (line 5):
Claim # (found on EOB ICN#):
NPI (Provider ID)(line 56):
Insurance ID (member ID)(line 60):
Admittance Date (line 6):
Discharge Date (line 6): same
Total Charges: $
Called UHC 877-842-3210, spoke with Jessica- she stated that the Medicare Advantage portion has reprocessed for payment in the amount of $1064.72 on 1/10/2021 for claim number 20K750034101 but has not released the check yet and there is no check date assigned, nor any check details obtained at this time. BLS will be able to claim full payment once released and received. Ref #5665; fully funded
What action code do I use for this f/u call?
DPC