ISSUES AND INSTRUCTIONS FOR TYPICAL AR AND DENIAL MANAGEMENT SCENARIOS
We have compiled a list of issues and actions for common AR and Denial Management scenarios. This will help you evaluate your current process and identify gaps.
Top 12 AR & Denial Management Scenarios
Scenario 1 – When Claims Are Not on File
Key Points to Analyze
- Claim mailing address
- Fax number
- Doctor’s referral letter
- Correct fax recipient
- Enrollee eligibility status
- Member not on the list
- Date limits
- Filing period
- Verification of ID and group number
Questions to Be Asked
- May I have the claim mailing address?
- Could you please provide the fax number, and should I proceed with faxing the claim?
- Should I verify the patient’s eligibility status to confirm entitlement on the date of service (DOS)?
- May I check with the payer to confirm the member’s availability?
- What is the filing limit for this claim?
Scenario 2 – When the Claim Is in Process
Key Points to Analyze
- Claim received date
- Claim processing time
- Technical protocols for filing a claim
Questions to Be Asked
- Can I have the claim receipt date?
- What is the general timeline for processing the claim?
- What are the technical protocols and standards for filing this claim?
Scenario 3 – When the Claim Is Forwarded to the Payer from the Billing Center
Key Points to Analyze
- Claim forwarded date
- Acknowledgment receipt
- Payer contact number
Questions to Be Asked
- Can you confirm the date the payer received the claim?
- Could you provide the payer’s contact information?
Scenario 4 – When the Claim Is Paid
Key Points to Analyze
- Claim number
- Paid amount
- Allowed amount
- Check date
- Patient responsibility
- Write-off amount
- Check cashed date
- Pay-to address
Questions to Be Asked
- Can you provide the check number and date?
- What is the allowed amount for this claim?
- What amount was paid for this DOS?
- Is there any write-off on this claim?
- What is the patient’s responsibility for this claim?
- Can you verify the pay-to address?
- Has the check been cashed?
Scenario 5 – Claim Paid to the Wrong Address
Key Points to Analyze
- Correct pay-to address
- Electronic Fund Transfer (EFT) setup
- W-9 form
- Telephonic appeal to update address
- Copy of the canceled check if already cashed
- Appeal to halt payment and reissue the check if not cashed
Questions to Be Asked
- Can you verify the doctor’s correct pay-to address?
- Was the claim filed electronically via EFT?
- Can you update the records if the correct pay-to address is provided?
- Could you provide the fax number to send the updated address?
- Can I fax the updated W-9 form?
- Can you fax a copy of the canceled check if it has been cashed?
- Can you halt the payment and reissue the check to the correct address?
Scenario 6 – Claim Denied for Untimely Filing
Key Points to Analyze
- Filing limit
- Claim denial date
- Re-filing and appeal contact information
- Proof of timely filing
- Fax number
Questions to Be Asked
- What is the claim denial date?
- What is the filing limit for this claim?
- What is the contact address for submitting an appeal?
- Could you provide the fax number?
- May I fax the appeal to your attention?
Scenario 7 – Claim Denied for Non-Covered Services
Key Points to Analyze
- Claim denial date
- Exclusion policies
- Claim summary
- Billing information for non-covered services
- Patient billing eligibility
- EOB appeal
Questions to Be Asked
- What is the denial date for the submitted claim?
- Is the patient enrolled in the program for billing services?
- Which services are not covered under the current insurance plan?
- Can the patient be billed for this claim?
- Could you provide a copy of the EOB via fax or mail?
Scenario 8 – Claim Denied for Missing Primary Insurance EOB
Key Points to Analyze
- Claim denial date
- Eligibility at the time of service
- EOB benefits
- EOB request
- Fax number
- Maximum frequency for routine services
- Primary insurance coverage details
Questions to Be Asked
- What is the denial date of the claim?
- Can you send the primary EOB?
- Can I appeal the denial with a reconsideration request?
- Can the claim be reprocessed if I fax or mail the primary EOB?
Scenario 9 – Claim Denied for Coordination of Benefits (COB)
Key Points to Analyze
- Claim denial date
- Primary payer payment details
- No-fault carrier
- Other insurance information
- EOB request
- Fax number
Questions to Be Asked
- What is the denial date of the claim?
- Does the patient have any other insurance coverage?
- Can you provide a copy of the EOB via fax or mail?
Scenario 10 – Claim Denied Due to Capitation Arrangement
Key Points to Analyze
- Claim denial date
- Capitation contract effective date
- EOB request
Questions to Be Asked
- What is the claim denial date?
- What is the date of the capitation arrangement?
- Can you fax or mail a copy of the EOB?
Scenario 11 – Claim Denied for Missing Authorization Number
Key Points to Analyze
- Claim denial date
- EOB request
- Member ID
- Claim limit
- Authorization requirement on DOS
- Fax number
Questions to Be Asked
- What is the claim denial date?
- Is there an authorization number for the DOS?
- If the authorization number is available in the system, can the claim be reprocessed?
- If I fax the authorization number, can the claim be reprocessed?
- Can you send a copy of the EOB via fax or mail?
Scenario 12 – Claim Denied for PCP Referral
Key Points to Analyze
- Claim denial date
- EOB request
- PCP referral requirement
- Fax number
Questions to Be Asked
- What is the claim denial date?
- If a PCP referral is available, can the claim be reprocessed?
- If I fax the claim with the PCP referral number, can the claim be reprocessed?
- Can you send a copy of the EOB via fax or mail?
Let’s Get Started
If you’re looking to:
- Reduce AR days
- Recover denied revenue
- Lower billing overhead
- Improve payer follow-up efficiency
