Claim Paid

Scenario Occurrences:

• This scenario occurs when the claim is paid but payment information is not received yet or posted.

On Call Scenario:
                                                                                       Claim Paid
                                                                                              ↓
                                                                    What is the processed & paid date?  
                                                                                              ↓
                                                             What are the allowed amount, paid amount and
                                                   patient responsibility (Coins, Deductible or Co-payment)?

                                                                                              ↓
                                             Verify sum of PA and Patient Responsibility(PTR) equals to AA,
                                                   if not then probe the rep and get the correct information

                                                            Click here to validate payment information
                                                                                              ↓
                                                     Was payment done through Check or EFT/Credit Card?
                                                  ↙                                                                                         ↘
                                        Check                                                                                         EFT/Credit Card
                                           ↓                                                                                                           ↓
                              What is the check#?                                                                     What is the Transaction ID?
                                           ↓                                                                                                           ↓
                   Was it Single check or Bulk check#?                                              Was it single payment or Bulk payment?
                       ↙                                   ↘                                                                   ↙                                    ↘
           Single check                         Bulk Check                                      Single payment                    Bulk payment
                   ↘                                           ↓                                                             ↘                                          ↓
                       ↘                    What is the Bulk Amount?                                           ↘         What is the Bulk Payment Amount?
                           ↘                               ↙                                                                         ↘                             ↙
                 May I have the check mailing address?                                                                Is payment cleared?

                                           ↓                                                                                               ↙               ↓                ↘

               Validate address provided by rep with                                                        Yes      Not Provided         No
              the address available in box# 32 and 33                                                          ↓                ↓                     ↓

                      ↙                                                     ↘                                                           ↓                ↓                     ↓

                 Correct                                                   Incorrect                                             ↓                ↓                     ↓

                     ↓                                                                ↘                                    May I have the        ↓          EFT/Credit card

      Is the check cashed?                                                     ↘                              encashment date       ↓         payment takes 2-3

          ↙                     ↘       ↘  →  →  →                                  ↘                                       ↓              ↙           days for clearance

       Yes                        No                         ↘                           Provide correct     Could you please              but not more than
         ↓                            ↓                         Rep does not          check mailing        fax the EOB? If             7 days. So, if the paid
May I have the               ↓                      have encashment    address to rep &     not then mail it or         date has crossed 7 days
 encashment                   ↓                      date information?  ask to reissue new    provide the source         then it means payment
      date?                         ↓                                   ↓                           check              to get the EOB            might get cancelled. So,

         ↓                            ↓                       Could you please                  ↓                                  ↘                  verify same with rep &

Could you please        Is paid date          fax the EOB? If                rep agrees?                May I have        ask rep to reissue new

fax the EOB? If      crossed 45 days?      not then mail it                  ↙                ↘           the Claim# &                 payment
Not then mail it                   ↙ ↘           or provide the source          Yes                    No        Call ref                         ↓
 or provide the                 ↙        ↘             to get the EOB                 ↓                          ↘                                     rep agrees?

source to get the          ↙                ↘                           ↘        What is the TAT?       What is the                      ↙                    ↘

      EOB                    Yes                  No                          ↘                ↓                        reason?                      Yes                   No

        ↓                         ↓                         ↘                             →   May I have                 ↓                               ↓                       ↓

May I have the   Could you please       How many days           the claim# &    Can I get the fax#            What is         What is the

claim# & Call    run check tracker         will it take to                 Call ref#?      or mailing address             TAT?              reason?

       ref#?            to get the current       clear the check?                                     to send W9 form                  ↓                      ↓

                          status of  the check?              ↓                                                to update the correct              ↓              Could you

                                   ↓                       Could you please                                          address?               May I have      please fax the

                           Rep agrees                fax the EOB? If                                                  ↓                   the Claim# &     the EOB? If

                            ↙            ↘                not then mail it                                         May I have the         Call ref#?        not then mail

                        Yes              No          or provide the source                              Claim# & Call ref#?                             it or provide

                         ↓                  ↓              to get the EOB                                                                                                   the source to

            What is the TAT?     ↓                            ↓                                                                                                              the EOB

                         ↓                  ↓                  May I have the                                                                                                        ↓

    Could you please fax the EOB?       Claim# & Call ref#?                                                                                         May I have

    If not then mail it or provide the                                                                                                                               the claim# &

         source to get the EOB                                                                                                                                             call ref#?

                         ↓

        May I have the 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 paid through a check on the correct address and the check is encashed and you receive the EOB then you can note the account and send the EOB it for posting.
• If the claim is paid through a check on the correct address and the check is encashed and you do not receive the EOB then you can note the account.
• If the claim is paid through a check on the correct address and the check is not encashed and paid date has crossed 45 days and the rep agrees to run the check tracer to get the status of the check then you can set the follow-up for TAT provided by the rep.
• If the claim is paid through a check on the correct address and check is not encashed and paid date has crossed 45 days and the rep denies to run the check tracer then you can note the account.
• If the claim is paid through a check on the correct address and check is not encashed and paid date has not crossed 45 days then you can set follow-up for the days that will take to clear to check.
• If the claim is paid through a check on the correct address and check encashment detail is not available and you receive the EOB then you can note the account and send the EOB for posting.
• If the claim is paid through a check on the correct address and check encashment detail is not available and you do not receive the EOB then you can note the account.
• If the claim is paid through a check on an incorrect address and the rep agrees to reissue a new check then you can set the follow-up for the TAT provided by the rep.
• If the claim is paid through a check on an incorrect address and the rep denies to reissue a new check then you can send a W9 form to insurance if available.
• Most of the time rep denies to reissue a new check when they do not find the correct mailing address. So, we need to send a W9 form to update the mailing address.
• If the W9 form is not available then you can take the action as per the update. A W9 form needs to be asked to the client.
• If the claim is paid through EFT or Credit Card and the payment is cleared and you receive the EOB then you can note the account and send the EOB for posting.
• If the claim is paid through EFT or Credit Card and the payment is cleared and you do not receive the EOB then you can note the account.
• If the claim is paid through EFT or Credit Card and the payment clearance information is not available and you receive the EOB then you can note the account and send the EOB for posting.
• If the claim is paid through EFT or Credit Card and the payment clearance information is not available and you do not receive the EOB then you can note the account.
• If the claim is paid through EFT or Credit Card and the payment is not cleared and paid date has crossed 7 days and the rep agrees to reissue a new check then you can set the follow-up for the TAT provided by the rep.
• If the claim is paid through EFT or Credit Card and the payment is not cleared and paid date has crossed 7 days and the rep denies to reissue a new check then you can note the account.
• Click here to go to Quiz

Prepare Notes:

Source of Status:

* Call Website EOB

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

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Processed Date:

*

Paid Date:

*

Allowed Amount:

*

Paid Amount:

*

Deductible Amount:

*

Coinsurance:

*

Copayment:

*

Mode of Payment:

* Check EFT Credit Card

Check Number:

*

Transaction ID:

*

Is it Single/Bulk Payment:

* Single Bulk

Payment Amount:

*

Check Mailing Address:

*

Is check paid on correct address?:

* Yes No

Is check cashed?:

* Yes No Not Provided/Available

Is payment cleared?:

* Yes No Not Provided/Available

Encashment Date:

*

Is paid date crossed 45 days?:

* Yes No

TAT for Encashment of Payment:

*

Rep agrees to run Check Tracer:

* Yes No

TAT for Check Tracer:

*

Reason for not sending request for check tracer:

*

Rep agrees to reissue new check:

* Yes No

Rep agrees to reissue new payment:

* Yes No

TAT to receive new payment:

*

Reason for not reissuing new check/EFT/Credit Card payment:

*

W9 form Requested:

* Yes No

Fax# Provided/Available:

* Yes No

Fax#:

*

EOB Available on Website:

*   Yes No

Mailing Address:

*

Source to get EOB:

* Fax Mail Website

Website Name/Link:

*

Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*



In the below box, final notes will be displayed once you click on Submit button and this box is editable, so you can make the changes as per the requirement

Note: We are not saving any of your inputs or notes in the backend