Claim in Process

Scenario Occurrences:

• This scenario occurs when you call the insurance within the TAT (Turn Around Time) or if the insurance needs additional information from the provider or patient.
• TAT - It is the amount of time taken by the insurance to complete the claim processing.
• TAT should always be calculated from the received date of a claim.
  

On Call Scenario:

                                                                  Claim in process
                                                                              ↓
                                                      When did you receive the claim?
                                                                              ↓
                                                        What is the normal processing
                                                                     time or TAT?
                                                                              ↓
                                                       Calculate TAT from received 
                                                date and check if is it within the TAT?
                                                   ↙                                                       ↘
                                               Yes                                                         No
                                                 ↓                                                            ↓
                                      May I get Claim#                                   May I have the
                                         & Call ref#?                                        reason for delay?
                                                                                              ↙              ↓                ↘ ⟶ ⟶ ⟶
                                                                                          ↙                  ↓                                   ↓
                                                              Any Information    Information requested    Other Reasons
                                                                 or documents             from patient                   (Backlog)
                                                               requested from                     ↓                                   ↓

                                                                    provider                  Have you sent                  May I get

                                                                           ↓                       letter to patient?               Claim#  &

                                                          What documents/info            ↙                 ↘               Call ref#?

                                                                  requested?                Yes                    No

                                                                           ↓                         ↓                      ↓

                                                            May I have the            When did        May I get

                                                          address or Fax# to         you send        Claim#  &

                                                      send the document/info?   the letter?       Call ref#? 

                                                                          ↓                          ↓

                                                            May I get Claim#        May I get

                                                                & Call ref#?            Claim# &

                                                                                                Call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the claim is within the TAT then you should set follow-up for the remaining days.
• If the claim received date has crossed the TAT and the delayed reason provided as additional information requested from the provider then you can send the document to insurance if it is available and you have the authority to send it or else assign the claim to the correct department to send it.
• If the requested document is not available then take action as per the update. This document needs to get from the client.
• If the claim received date has crossed the TAT and the delayed reason provided as additional information requested from the patient and a letter is sent to the patient and the date when a letter was sent to the patient has not crossed one month then do not bill the claim to the patient and at least wait for a month before releasing it to the patient since it takes time to receive the letter to the patient and update the information with insurance. So, set the follow-up of 1 month from the letter sent date.
• One month of waiting time is given to the patient to update information but always follow your client's instructions whether we need to wait for one month or not.
• If the date when a letter was sent to the patient has crossed one month then release the claim to the patient.
• If the claim received date has crossed the TAT and the delayed reason is provided as additional information requested from the patient and the letter is not sent to the patient then you can release the claim to the patient.
• If the claim received date has crossed the TAT and the delayed reason is provided as backlog then you can set the follow-up for more days.
• When getting status as the claim is pending due to litigation then it takes a longer time for resolution since it is based on the court’s decision.
• Click here to go to Quiz

Prepare Notes:

Source of Status:

* Call Website

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

Insurance Name:

*

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Received Date:

*

Turn Around Time (TAT):

*

Is Claim Within TAT?

* Yes No

Reason for Delay:

* Any Document OR Info Requested From Provider Info Requested From Patient Other Reasons

What Document Requested?

*

Address to Send Document:

*

Is fax# provided by rep or available?

* Yes No

Fax#:

*

Is Letter Sent to Patient?

*  Yes No

Time Frame:

*

Date When Letter Sent:

*

Specify Reason:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Need to allow more time Claim released to patient Need client assistance



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