Scenarios
A claim is denied due to patient meeting their maximum. Walk me through the steps you would take and the activity you would choose..
Verify when and how much their maximum was, upload eob, route to audit.
When do we defer claims?
When we need to allow more time for a claim to reach a resolution
Where do we go to REVIEW nea's that have already been created?
Fastattach web online
The claim is denied for not being able to confirm which insurance is primary or secondary. Walk me through what your next steps would be and what activity you would choose..
Confirm if there is a COB/DIQ form on file, if not route to the office under coverage related.
What information should we verify when a claim is not on file?
Patients information, payor information, provider information
Where do we go to find information on a provider such as provider status, effective date, and etc?
Credentialing grid
A claim is pending for needing additional information such as a primary eob. The rep tells you they accept NEA's but the information has to be sent with a new claim. Walk me through what your next steps would be..
Confirm if the primary insurance claim has been billed out in epic. If so, see if the EOB is attached and submit the information via nea, override the ICN and add nea # in box 35. Use the activity Resubmit NEA with new claim.
When do we send claims to billing resubmission?
Claim needs to be resubmitted via paper
Payor does not accept electronic claim submissions
Payor is receiving claim with discrepancies
Claim has been submitted twice electronically and is still not on file
Claim needs to be billed with specific instructions
Corrected claim is needed
Where do we go to find xrays?
PDS Web Viewer
A claim is not on file. A rep tells you that you have the incorrect member ID. Walk me through what your next steps would be.
Confirm the correct patients ID, update it in the coverages tab. Resubmit claim.
What activity is used when coverage updates are needed and we have the correct information verified?
Route to Eligibility WQ
How do we upload EOB's in onbase?
Import, choose file, Billing, Paper EOB, input all key information, import
A claim was paid in 2025 and has not been cleared as of 04/17/2026. Walk me through what your next steps would be...
Confirm where the payment went, request stop and reissue to the lockbox and defer the claim.
What two additional actions must be taken when resubmitting a NEA with a new claim?
Override ICN and add NEA number in box 35
Where do we go to create a credentialing ticket?
Epic service desk