31: Patient cannot be identified as our insured

Denial Occurrence:

• This denial occurs when an incorrect patient name, Date of birth, or Gender is billed.

On Call Scenario:
                                                              Patient cannot be identified
                                                                                  ↓
                                                   Could you please search the patient with  
                                                         Name, DOB or Social Security#?
                                                   ↙                                                           ↘
                               If rep finds the patient                                           If rep unable to find patient
                                                 ↓                                                                                    ↓
                        May I have the correct policy ID?                                          May I get call ref#?

                                                 ↓

                         Could you please check if claim
                     is available for the DOS with correct
                                        member ID?
                           ↙                                               ↘
                     Yes                                                       No
                      ↓                                                              ↘
        Follow AR Scenario                             May I have the effective and
 Tool as per the claim status                           termed date of the policy?
             Click Here                                                             ↓
                                                                      Check if DOS lies between
                                                                       effective and termed date
                                                                   ↙                                               ↘
                                                               No                                                   Yes
                                                               ↓                                                        ↓
                                                  May I get call ref#?                        May I have the Timely
                                                                                                             filing limit(TFL)?
                                                                                                                         ↓
                                                                                                  Check DOS lies within TFL
                                                                                                ↙                                            ↘
                                                                                           Yes                                              No
                                                                                        ↙                                                      ↓
                                                               May I have claim                       Can we fax or mail the
                                                                mailing address,     ←              claim along with POTF?
                                                              Payer ID and Fax#?       ↖          ↙                                ↘
                                                                              ↓                         ← No                                  Yes
                                                                May I get call ref#?                                                        ↓
                                                                                                                                     May I have Fax#
                                                                                                                                    or Mailing address
                                                                                                                                   to send claim along
                                                                                                                                        with POTF?
                                                                                                                                                ↓
                                                                                                                                  May I get call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the rep is unable to find the patient or when this denial occurs then the claim can be released to the patient if no other active insurance is available.
• Before releasing the claim to the patient, check the web portal of the insurance if access is available to verify the patient's information.
• Always check previous DOS, if payment from any other insurance was received or not. If yes, then check the eligibility for that payer for DOS and resubmit the claim if the patient policy is active.
• If the rep is able to find the patient and claim after the Name, DOB & SSN search then follow the AR scenario as per the status of the claim.
• If the rep is able to find the patient but not the claim and the patient's policy is not active on DOS then the claim can be released to the patient if there is no other active insurance available.
• If the rep is able to find the patient but not the claim and the patient policy is active on DOS and DOS lies within TFL and the payer ID & mailing address are the same as the system details then you can resubmit the claim.
• If the rep is able to find the patient but not the claim and the patient policy is active on DOS and DOS has crossed the TFL and the rep confirms that you cannot fax or mail the claim along with POTF then resubmit the claim. Once TFL denial receives then you can send an appeal with POTF.
• If the rep is able to find the patient but not the claim and the patient policy is active on DOS and DOS has crossed the TFL and the rep confirms that you can fax or mail the claim along with POTF then fax/mail the claim along with POTF. (Sometimes, the client wants to resubmit the claim instead of mailing or faxing the claim with POTF and waiting for TFL denial, and then sending the appeal. So, work as per the instructions.)
• If the rep is able to find the patient but not the claim and there is no POTF and the claim was billed after TFL was crossed then the claim needs to be written off.
• For Medicare, it is necessary to have the correct policy ID, Name, and DOB as mentioned in the ID card, or else it will be denied as the patient cannot be identified. Medicare policy format has now changed from HIC to MBI. Both have 11 characters whereas the HIC number has a suffix at the end of the SSN and MBI has 11 characters in alpha-numeric format.
• Click here to know about MBI
• When you received an ID denial from Medicare and you have an MBI number but there is a patient name issue then you can search for the correct last and first name on the web portal. Sometimes last and first names are replaced with each other. Also, you can try to pull the patient by adding Jr, Sr, I, II, III, and IV in the last name.
• Never billed Medicare ID denial to supplementary plan because they would also deny the claim stating primary insurance denied the claim, so they will not process the claim.
• BCBS policy format has 3 characters alpha prefix and If the claim is billed without the prefix, it will get denied for a patient not identified. These prefixes are based on state and if you have the SSN of the patient then you can pull the patient on the Availity web portal, this trick is not 100% accurate but works sometimes. For example, for NM state, use YIF or XIF followed by SSN. For the MI state, use XYL followed by SSN, etc. Similarly, you can find the prefix details for the state you are working in and try with SSN.
  
• Click here to go to Quiz

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Is Claim Denied?:

* Yes No

Denial Date:

*

Was rep able to find the patient after First name, Last name, DOB or SSN search?:

* Yes No

What was incorrect?:

* First Name Last Name Complete Name DOB Policy ID

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Claim released to patient Updated the correct patient name and resubmitted the claim Updated the correct DOB and resubmitted the claim Updated the correct Policy ID and resubmitted the claim Need client assistance



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