PD207-Insurance Claims Follow-up and Claim Status

Category: Education

Presentation Description

in-service on how to follow up on unpaid claims


Presentation Transcript

PD207-Insurance Claims Follow-up and Claim Status:

West Valley Educational Group, LLC PD207-Insurance Claims Follow-up and Claim Status

PowerPoint Presentation:

When insurance claims are submitted either via paper or electronically, it is very important to track any claim not paid within 30 days. Each Friday an AR report should be generated and reviewed, once you have identified all claims which have not been paid you want to begin contacting the insurance company to obtain a status.

Claim Status :

Claim Status It is good practice to establish a relationship with the each payer and communicate with the appropriate health plan representatives within each plan's claims and appeals processes. The purpose of obtaining claim status is to trace any claim that has not been paid by an insurance carrier.

PowerPoint Presentation:

There are (3) ways to obtain claim status depending on the carrier: When calling an insurance company to research the status of a claim, there are specific questions you will be asked in order to get the information you need to determine how to proceed with follow up.

Claim Status Methods :

Claim Status Methods

Websites :

Websites Most insurance carriers will allow you to access claim status information via health plan website. In almost all cases, you will need to register the practice to gain access to the database.


Phone You may contact the insurance carrier to obtain a claim status over the phone. Prior to calling you must have the patient’s name, date of birth, insurance ID number, date of service and billed amount. You will also need the provider’s tax ID number.


Mail/Fax Depending on the insurance carrier, forms are available for obtaining claim status inquiries. Check the carrier’s website or provider handbook for instructions and forms.

PowerPoint Presentation:

After speaking with the insurance representative, document in the patient’s financial account the name of the person you spoke with , status of claim (denied, pending) reason for claim denial and what needs to be done to get the claim resolved and paid.

Example of a typical claim status call conversation :

Patient John Andrews Example of a typical claim status call conversation

Patient John Andrews claims status call :

Patient John Andrews claims status call Insurance Rep : Thank you for calling Hillside Insurance, my name is Alex how can I assist you today? Medical Biller : Hello, I need a claim status Rep: Sure, I will be happy to assist you, who am I speaking with? Biller: This is Gina. Rep: Hi Gina, where are you calling from ? Biller: Florida Care Physicians

Patient John Andrews claims status call :

Patient John Andrews claims status call Rep : May I have the provider tax ID number? Biller: 860995952 Rep: Name of the provider? Biller: Steven Columbus. Rep: o.k., may I have the member ID number?


Biller: 305686985 Rep: Thank you, please verify the patient’s name and date of birth Biller: John Andrews, 1-27-1954 Rep: Thank you, what’s the date of service? Patient John Andrews claims status call

Patient John Andrews claims status call :

Patient John Andrews claims status call Biller : 5-5-2012 Rep: and the billed amount? Biller: $65.00 Rep: Thank you ……….I show the claim was paid on June 12,2012

Claim Status :

Claim Status Biller: Do you have a check number? Rep: yes, that check number is 10017620000 Biller : What is the check address? Rep: the check was mailed to 12245 N. Creek , suite 101 Phoenix, Arizona 85001

PowerPoint Presentation:

Biller : Can you tell me if the check cleared the bank? Rep: Sure please hold for that information………….yes, that check was cashed on June 22, 2012 Biller: Thank you Rep: Is there anything else I can assist you with? Biller: no, that’s it for now, thanks Alex. Rep : Thank you for calling Hillside Insurance, have a nice day!

Claim Denials :

Claim Denials

Claim Denials:

Claim Denials Most claim denials occur due to data entry errors , other denials are related to missing or invalid information. Here are ten reasons for claim denials and suggestions on how to correct the problems

Common reasons for claim denials :

Common reasons for claim denials 1. Missing/invalid procedure and/or ICD 9 code (s) 2. Missing/invalid Provider Tax ID/ Insurance Provider number 3. Missing/invalid member ID number 4. Missing reports or EOB from primary payer 5. Missing referring Physician information (name/NPI#) 6. Missing Modifiers (when applicable)

Common reasons for claim denials :

Common reasons for claim denials 7. Past timely filing limit (varies by insurance payer) 8. Patient coverage terminated 9. Missing secondary insurance information on the claim 10. Duplicate claim 11. Missing/invalid place and/type of service 12. Prior authorization not on file

Duplicate Claim Denials :

Duplicate Claim Denials To avoid duplicate claim denials, please allow 20-30 business days for your claim(s) to be processed. If you haven’t received a Remittance Advice, and you submit your claim(s) again, you may receive the duplicate claim denial before you receive the Remittance Advice for the first submission detailing the payment or denial of services. Before you resubmit a claim, please check for information on the status of your claim(s) and to verify receipt of your claim.

Notes in Practice Management Program :

Notes in Practice Management Program Each time you follow up on a claim, make changes to claim information, contact insurance carrier and/or patient, it is crucial to add notes in the billing system for tracking purposes. This also helps if you ever leave the company or need someone to cover for you while you’re on vacation/sick leave etc. Posting notes also helps you keep track of your progress as you begin working your A/R, claim status, appeals etc.

Resubmissions :

Resubmissions When a claim is resubmitted usually it means there was a data entry error made or you submitted invalid information such as a procedure or ICD 9 code. Examples of reasons a claim may be resubmitted is, missing provider information, missing primary insurance EOB, incomplete claim (required fields have not been completed) In these cases all that needs to be done is to make the corrections and resubmit. Again be very aware of how much time you have to resubmit for payment.

Steps for Maximizing Reimbursement :

Steps for Maximizing Reimbursement Update medical billing software with most current CPT and ICD-9 codes when codes are changed. Run A/R reports weekly to identify claims which have not been paid in at least 30 days. Encourage patients to complete registration forms legibly and accurately to avoid claim denials for invalid information

Steps for Maximizing Reimbursement :

Steps for Maximizing Reimbursement Obtain clear copies of patient insurance cards (front and back) Conduct patient financial interviews during the first visit to review financial policies and procedures for the medical practice. Keep a list of all timely filing limits for all health plans the office submits claims to.


References State of Florida Department of Health (2010) Provider guidelines: Medical Quality of Insurance, 2010, September . The Health Insurance Claims Basics. (nd). Retrieved November 8, 2010, from Bills.com: http://www.bills.com/health-insurance-claims-process Hicks, J. (nd). Improve AR Days with Claim Follow Up. Retrieved January 5, 2011, from About.com: http://medicaloffice.about.com/od/claims/a/Improve-Ar-Days-With-Claim-Follow-Up.htm

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