AR Analyst Process (How to work an account, Preparing Notes & Non Callable Denials)

When working on an account, you need to go through 3 phases to complete any account:

    1. Analysis

    2. Research
    3. Action

1) Analysis:

• In this phase, you need to find out the current status of an account by following the below steps,

• Check if any EOB is received or posted on an account. If you are working on denials then the account will definitely have a denial posted.

• On the no response claim, if you are not able to find any EOB in the system then check the clearing house, you can find an EOB on the clearing house which has not been posted in the account yet or you can get the rejections on the clearing house.

• Always check previous notes, it will help you to identify if an account is previously worked by anyone or not. If you find the previous notes then read them carefully to understand the previous actions.

2) Research:

• In this research phase, you have to utilize a website or make a call to collect the required information and when making calls always keep the "AR scenario" open to ask suitable questions. Sometimes, you can also complete an account without utilizing websites or making calls. For example, If you identified that a claim was denied for coding-related issues then you can directly task the claim to the coding team.

3) Action:

• In this phase, you have to take appropriate action on the system along with preparing & pasting notes. 

To understand the above phases on an account, we will go through with a few examples. Hopefully, it will be more helpful.

Example 1:

Analysis - There is no EOB in the system as well as on the clearing house and the claim is not rejected through the clearing house. Also, there are no previous notes.

Research - Since there is no EOB, you will need to utilize the website to find the claim status if website access is available. If website access is not available then will need to make a call for the status. We will go through both the examples - On call & website utilization.

On Call:

• Suppose you called the insurance and spoke with Maria and got the status as "Claim not on file" then open this scenario and as per the scenario, suppose you already collected all the required information as highlighted in red below,

                                                                  No claim on file

                                                                              ↓

                                                May I have policy effective and termed date?

                                          (Effective Date - 01/01/2020 & policy is still active)

                                                                              ↓

                                             Check DOS lies between effective and termed date

                                                               (DOS is 02/05/2021)

                                            ↙                                                                                ↘

                                        Yes                                                                                 No
                                           ↓                                                                                    ↓

    (TFL - 365 days) May I have the TFL ← ←                                     Is there any other policy
                                           ↓                               ↖                             active for the patient on DOS
                        Check DOS lies within TFL           ↖                              ↙                            ↘
             (Consider the current date as 06/21/2021)        

                              ↙                             ↘                       ↖                      Yes                            No
                          Yes                                No                      ↖                     ↓                               ↓
                            ↓                                   ↓                           ←    May I have                  May I get
             May I have claim             Can we fax# or                    Policy ID, Policy             call ref#
              mailing address,               mail the claim                        effective and
             Payer ID and Fax#          along with POTF                      termed Date
  (Mailing address & payer ID              ↙↘

         are same as in system                 ↙     ↘

            & fax#1234567890)                ↙         ↘

                           ↓               ↖            ↙              ↘
             May I get call ref#     ↖  ← No              Yes
                     (12345)                                             ↓
                                                                  May I have Fax#                   
                                                                or Mailing address
                                                                to send claim along
                                                                     with POTF
                                                                             ↓
                                                                 May I get call ref#

Website:

• If you have access to the insurance portal to check eligibility and claim status then you can obtain all the above answers through the web portal as well. First, check the claim status, it would ask to enter policy ID, patient name, DOB and DOS. Enter all the information correctly and submit. It would not pull any claim then open the above "claim not on file" scenario and move step by step. Next, you need to verify the patient's effective date and termed date. So, check the eligibility to find out whether the patient is active on DOS or not. TFL can be obtained through google search and you can also find the claim mailing address and payer ID on the portal.

(Note: Always have the AR scenario in front of you to collect all the required information through a call or website. Sometimes, the website does not provide all the information. In such cases, you would need to make a call.)

Action - Here, we identified that the claim is not received by insurance and DOS is within TFL and you have also verified the mailing address and payer ID which is the same. So, your action would be resubmitting the claim. 

This example may be very simple to identify the next action as "Resubmitting claim to insurance". But at the start, you might find it difficult to identify correct action. So, we have added an "Important Note" section in each AR scenario which will be helpful to identify actions. Also, it would be better to get help from tenure folks or supervisors of your project.

Preparing Notes:

When preparing notes, always remember that it would include all 3 phases of information, it would start with analysis then research, and at the end action part. So, first, mention all the information that you identified in each phase,

Analysis - Checked in the system there is no EOB, checked the clearing house unable to find EOB.

Research - In the research part, you have to make a call & utilize the website and all answers you can see above scenario, so to make sure that you are not forgetting any information, always move step by step as per the scenario then your notes would be,

Call Notes:
Called insurance and spoke with Maria, as per the rep claim is not on file, the patient's policy is effective from 01/01/2020 and is still active, TFL is 365 days and the claim mailing address and payer ID is the same as in the system, fax# 1234567890. Call ref# 12345.

Website Notes:

As per the website, the claim is not on file, checked the eligibility patient is active on DOS, TFL is 365 days and claim mailing address and payer ID is same as in the system.

Action - Claim Resubmitted.

Now we will combine all 3 phases of information together and create final notes,

Final Call Notes:
Checked in the system there is no EOB, checked the clearing house unable to find EOB. Called insurance and spoke with Maria, as per the rep claim is not on file, the patient's policy is effective from 01/01/2020 and is still active, TFL is 365 days and the claim mailing address and payer ID is the same as in the system, fax# 1234567890. So, resubmitted the claim. Call ref# 12345.

Final Website Notes:

Checked in the system there is no EOB, checked the clearing house unable to find EOB. as per the website claim is not on file, checked the eligibility patient is active on DOS, TFL is 365 days, and the claims mailing address and payer ID is same as in the system. So, resubmitted the claim.

(Note: This is a general notes format that will differ from your client-specific format where you might need to enter additional information or follow a specific format, so always follow the client-specific format.)

Example 2: 

Analysis - There is an EOB in the system and the denial reason is "26: Expenses incurred prior to coverage". Also, there are no previous notes.

Research - Since there is a denial reason available, open the same denial scenario to know what information you need to collect to resolve the claim. If you have website access and are able to get the answer to all mandatory questions from the website then you won't need to call the insurance. But, if you are unable to get the answer to mandatory questions through the website then you will need to call and verify it. Most of the time this denial can be solved without calling but always follow your client's update. 

On Call:

• Suppose you called the insurance and spoke with Maria and got the answer to all the questions as highlighted in red below,

                                                          Claim denied as member coverage 
                                                              terminated or Policy termed
                                                                                  ↓
                                                                May I get the denial date?

                                                                       (05/31/2021)
                                                                                  ↓
                                                May I have the policy effective and termed date?

                                      (Effective date - 01/01/2020 & termed date - 12/31/2020)
                                                                                  ↓
                                             Check if DOS lies between effective and termed date

                                                                   (DOS - 03/28/2021)
                                            ↙                                                                                  ↘
                                        Yes                                                                                    No
                                          ↓                                                                                       ↓
                     Could you please send the                                                   Is there any other policy      
                    claim back for reprocessing                                             active for patient on DOS (No)
                     since policy active on DOS                                              ↙                                 ↘
                                         ↓                                                               Yes                                    No

                           What is the TAT for                                                 ↓                                       ↓

                                reprocessing?                                May I have policy ID,               May I have the 

                                        ↓                                              Policy effective and               claim# & call ref#

                          May I get the Claim#                                  termed date                       (Claim# 2586 &

                               & Call ref#?                                                   ↓                                 Call ref# 1234)

                                                                                       May I have the claim# 
                                                                                               & call ref#

Important Note:

• This denial 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 eligibility information.
• When other insurance is available then check eligibility for that insurance and if the patient is active for that insurance then make it primary and resubmit the claim. 
• 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.

(Note: We have added this "Important Note" section with each scenario to help you in deciding the correct action. But, always follow your client-specific update before taking an action as per "Important Note", it may differ.)

Website:

• If you have access to the insurance portal then you can obtain all the above answers through the web portal as well. You can find out the denial date on EOB and whether the patient was active or not, can also be verified by checking eligibility.

Action - Here, you found that the patient was not active on DOS and to take the appropriate action, just read the "Important Note" section which states that you need to check your insurance history if there is any other insurance available. If yes then will need to check the eligibility of that insurance and need to bill the claim to that insurance if active on DOS. If no other insurance is available then you can release the claim to the patient. We will consider that there is no other insurance for this claim, so will release the claim to the patient.

Preparing Notes:

When preparing notes, always remember that it would include all 3 phases of information, it would start with analysis then research, and at the end action part. So, first will mention all the information that you identified in each phase,

Analysis - Checked in the system there is an EOB and claim denied for 26: Expenses incurred prior to coverage.

Research - In the research part, you have to make a call or utilize the website and all answers you can see above scenario, so to make sure that you are not forgetting any information, always move step by step as per the scenario then your notes would be,

Call Notes:
Called insurance and spoke with Maria, as per the rep claim was denied on 05/31/2021 and the patient was effective from 01/01/2020 and termed on 12/31/2020. There is no other active policy active on DOS. Claim# 2586. Call ref# 1234.

Website Notes:
As per the website claim was denied on 05/31/2021 and the patient was effective from 01/01/2020 and termed on 12/31/2020. There is no other active policy active on DOS.

Action - There is no active policy on DOS and no other active insurance in the system. So, the claim needs to be released to the patient.

Now we will combine all 3 phases of information together and create final notes,

Final Call Notes:
Checked in the system there is an EOB and claim denied for 26: Expenses incurred prior to coverage. Called insurance and spoke with Maria, as per the rep claim was denied on 05/31/2021 and the patient was effective from 01/01/2020 and termed on 12/31/2020. There is no other active policy active on DOS and no other active insurance in the system, so the claim released to the patient. Claim# 2586. Call ref# 1234.

Final Website Notes:

Checked in the system there is an EOB and claim denied for 26: Expenses incurred prior to coverage. As per the website claim was denied on 05/31/2021 and the patient was effective from 01/01/2020 and termed on 12/31/2020. There is no other active policy active on DOS and no other active insurance in the system, so the claim released to the patient.

(Note: This is a general notes format that will differ from your client-specific format where you might need to enter additional information or follow a specific format, so always follow the client-specific format.)

Non-Callable Denial:

Below are the general non-callable denial categories but it is dependent on your client update as well. Sometimes, the client wants us to make a call on these denials, so first go through with the updates of your business or process to bifurcate the callable and non-callable denials category.

1) Eligibility Denials:

31: Patient cannot be identified as our insured

26: Expenses incurred prior to coverage

27: Expenses incurred after coverage terminated

22: This care may be covered by another payer per coordination of benefits

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

140: Patient/Insured health identification number and name do not match

MA04: Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible

• All the above are eligibility-related denials that can be worked by utilizing the website. If website access is not able then to follow your client update.

• There are more eligibility-related denials that can be included in the above list. Try to identify it by the denial description.

2) Coding Denials:

4: The procedure code inconsistent with the modifier used or a required modifier is missing

6: The procedure/revenue code is inconsistent with the patient's age

7: The procedure/revenue code is inconsistent with the patient's gender

9: The diagnosis is inconsistent with the patient's age

10: The diagnosis is inconsistent with the patient's gender

11: The diagnosis is inconsistent with the procedure

49: This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam

146: Diagnosis was invalid for the date(s) of service reported

181: Procedure code was invalid on the date of service

182: Procedure modifier was invalid on the date of service

• Coding-related denials can be directly assigned to the coding team but always check your client update first to work the account correctly.