163: Attachment/other documentation referenced on the claim was not received

On Call Scenario:

                                                       Claim denied for primary EOB
                                                                            ↓
                                                          May I get the denial date?
                                                                            ↓
                                  Check your system, the insurance on which you have 
                               made the call is listed as primary or secondary insurance
                                   ↙                                                                         ↘
                     Primary Insurance                                              Secondary Insurance
                                  ↓                                                                             ↓
           Could you please tell me which                         Check if payment from primary
        insurance is the primary insurance?                       insurance is received/processed
                                  ↓                                           by primary that can be billed to secondary 
                      Rep provided?                                                       ↙                       ↘
                   ↙                        ↘                                              Yes                            No
              Yes                           No                                         ↙                                    ↘
                ↓                              ↓                     Check box# 29 in CMS             Follow up with primary
What is the policy        May I have the       1500 form if paid amount of       insurance & work claim
   id, payer id &         claim# & call ref#?   primary insurance is available,         as per primary
mailing address for                                        if yes then it means that                  insurance status

primary insurance?                                      primary paid details already
               ↓                                                             sent to insurance
   May I have the                                             ↙                                   ↘
claim# & call ref#?                                    Yes                                       No
                                                                  ↙                                               ↘
                              Could you please reprocess the claim                       What is the Fax# or mailing
                             as primary payment details are already                          address & time limit to

                                  sent on claim form in box# 29?                                      send the EOB?

                                      ↙                                     ↘                                                   ↓
                     If rep says it still                     Rep sent claim back                   May I have the
                        not received                            for reprocessing                    claim# & call ref#?
                                 ↓                                                  ↓
                   What is the Fax# or                     What is the TAT
                 mailing address & time                 for reprocessing?
                 limit to send the EOB?                               ↓
                                ↓                                       May I have the
                    May I have the                          claim# & call ref#?
                 claim# & call ref#?

Important Note:

• If the rep does not provide 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 and primary paid information does not go through on the first attempt then you can resubmit the claim and check the claim form whether paid details are now available or not(CMS 1500 - Box# 29 & UB 04 - Locator# 54), if it is still missing then send EOB through fax or mailing address.
• If the time limit to submit the primary EOB is already passed then write off the charge or follow your client's instructions.
• Always check the remark code given with the denial reason, sometimes it provides the exact reason for denial that could differ. So follow the AR scenario tool to work the exact denial.