227: Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete

Denial Occurrences:

• This denial occurs when any information is requested from the patient such as COB or others.
• When information is requested from a patient, a letter is sent to the patient and it may take time to get the update from the patient. So, we should at least allow 15-30 days from the date when the letter is sent before releasing it to the patient.
• COB: It stands for Coordination of Benefit and it helps to determine which insurance is primary, secondary, or tertiary.

On Call Scenario:

                                                   Claim denied/pending as additional
                                                    information requested from patient
                                                                              ↓
                                                      When did you receive this claim?
                                                                              ↓
                                                           May I get the denial date? 
                                                                (If claim is denied)
                                                                             ↓
                                         What information have you requested from patient?
                                            ↙                                                                      ↘
          Patient needs to update COB information                               Other Reasons
                                           ↓                                                                          ↓
                     Have you sent letter to patient?                          Have you sent letter to patient?
                        ↙                                  ↘                                      ↙                                   ↘
                    Yes                                   No                                 Yes                                   No
                      ↓                                      ↓                                    ↓                                       ↓
           When did you            When did patient last          When did you                  May I get the
           sent the letter?              update the COB                sent the letter?            claim# and Call ref#?
                      ↓                           information?                            ↓
        Have you received                       ↓                        Have you received
        any response from             May I get the               any response from
                 patient?               claim# and Call ref#?                patient?
            ↙                   ↘                                                     ↙                  ↘
         Yes                     No                                             Yes                     No
           ↓                           ↘                                             ↓                            ↘
     Could you             When did patient                   Could you                May I get the
 please reprocess          last update the                  please reprocess     claim# and Call ref#?
      the claim?            COB information?                 the claim?
           ↓                                   ↓                                      ↓
What is the TAT            May I get the                 What is the TAT

for reprocessing?     claim# and Call ref#?         for reprocessing?

           ↓                                                                           ↓

  May I get the                                                       May I get the
claim# and Call                                                    claim# and Call
        ref#?                                                                     ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the COB/Other information is requested from the patient and the letter has already been sent and the response has also been received from the patient and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the COB/Other information is requested from the patient and the letter has already been sent but the response has not been received from the patient then the claim can be released to the patient.
• If the date when the letter was sent to the patient has not crossed 30 days then do not bill the claim to the patient. At least provide 30 days for the patient to update the information and once 30 days are crossed then bill the claim to the patient. But, always follow your client's instructions.
• If the COB/Other information is requested from the patient and the letter is not sent then the claim can be released to the patient.
• When the claim is denied or pending for COB updation then you can check the patient's payment history if the payment on nearby DOS was received from any other insurance as primary insurance then check the eligibility of that insurance and bill the claim to that insurance if the policy is active on DOS as primary.
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