109: Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor

On Call Scenario:

                                                 Claim denied as other payer is primary
                                                                             ↓
                                                           May I get the denial date?
                                                                             ↓
                                                     Could you please tell me which 
                                                   insurance is the primary insurance?
                                                                             ↓
                                                        Does rep have the details?
                                                        ↙                                       ↘
                                                    Yes                                          No
                                                 ↙                                                     ↘
                             What is the effective &                          May I have the claim# 

                           termed date of the policy?                               & call ref#?

                            ↙                                    ↘

           Rep have the details            Rep does not have details

                          ↓                                               ↘

       Was policy active on DOS?          What is the policy id, payer id

               ↙                            ↘               & mailing address of primary

            Yes                               No                         insurance?

              ↓                                  ↓                                  ↓

      What is the              Could you please           May I have the
 policy id, payer id       reprocess the claim      claim# & call ref#?

  & mailing address    since there is no active

       of primary              primary insurance?  

       insurance?                          ↓

             ↓                       What is the TAT?

  May I have the                        ↓

claim# & call ref#?         May I have the

                                     claim# & call ref#?

Important Note:

• If the rep does not have primary insurance details then checked in the system if there is any other insurance available or patient's payment history has any other insurance as primary, if yes then check eligibility for that insurance and resubmit the claim to that payer if the policy is active as primary or else release the claim to the patient if the policy is inactive or no other insurance information available.
• You can also check the payer web portal to get primary insurance details if access is available.
• When the rep provides the primary insurance information and you have web portal access for primary insurance then always verify eligibility through the website, there could be a possibility that primary insurance is inactive on dos then ask insurance to reprocess the claim.
• When the rep provides all details of primary insurance then you can update that insurance as primary and make current insurance secondary insurance and resubmit the claim to primary insurance.
• If the claim is already paid by primary insurance then Click Here to follow primary EOB scenario.

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:

*

Denial Date:

*

Did rep provide the primary insurance information?/Is primary insurance information available?:

* Yes No

Name of the primary insurance:

*

Is Coverage Details Available?:

* Yes No

Policy Effective Date:

*

Is policy still active?/No Termed Date:

* Yes No

Policy Termed Date:

*

Is Policy Active on DOS?:

* Yes No

What is the TAT?:

*

What are the other infomration available/provided by rep:

* Policy ID Policy ID and Payer ID Policy ID and Mailing Address Payer ID and Mailing Address Policy ID, Payer ID and Mailing Address None

Policy ID:

*

Payer ID:

*

Claim Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Claim released to patient Updated the correct primary information and resubmitted the claim Need client assistance Need to allow more time



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