CO29 To Claim not on File (Day 6)

Question 1

Difference Between

Denial Claims and Rejected Claims

Answer 1

• Once Insurance Company accept claim, they will adjudicate whether it will be Payed or Denied i.e. Denial Claims
• If there are any errors or mistakes in the claim form, we will get rejection from the Clearing House i.e. Rejected Claims

Question 2

Difference Between

ABN and WL

Answer 2

• ABN is for Medicare.
• WL is for Commercial.

Question 3

How will you handle a “Claim Denied for Untimely Filing Limit (CO29)” case?

Answer 3

I would handle a “Claim Denied for Untimely Filing Limit” case by first asking the denial date from the insurance representative. Then, I would inquire about the received date of the claim and further I would ask TFL as per insurance guidelines. If the claim is within TFL, I’d request the representative to reprocess the claim and gather information such as the TAT period, claim number, and reference number. My final action would be follow up after the TAT period.

If the claim crossed the TFL and if the POTFL states that the claim was submitted within the TFL then, I would ask for appealing with POTFL and gather information such as AFL, Appeal address, fax number, claim number and reference. My final action would be to send an appeal with POTFL.

If the POTFL states that the claim was not submitted within the TFL then I’d request the claim number and reference number from the representative, and my final step would be to adjust/writeoff the claim.

Question 4

What is POTFL?

Answer 4

POTFL stands for Proof Of Timely Filing Limit.
1) If the claim is sent via Mail, then Tracking ID of Courier receipt will be POTFL.
2) If the claim is sent via Electronic, then Transaction ID of Clearing House will be POTFL.

Question 5

Capitation Period

Answer 5

For a certain period of time PCP received advance payment from the Insurance Company is called Capitation Period.

Question 6

How will you handle a “Claim Denied for Capitation Period” case?

Answer 6

I would handle a “Claim Denied for Capitation Period” case by first asking the denial date from the insurance representative. Then, I would inquire about the start and end dates of the Capitation Period. If the claim would be within the Capitation Period then, I’d request the claim number and reference number from the representative, and my final step would be need to task to Payment Posting Department.

If the claim would’ve crossed the Capitation Period, I’d request the representative to reprocess the claim and gather information such as the TAT period, claim number, and reference number. My final action would be to follow up after the TAT period.

Question 7

How will you handle a “Claim not on File” case?

Answer 7

I would handle a “Claim not on File” case by first asking the start and end date of the Policy from the insurance representative. Then, I would inquire whether the policy is active or inactive.

If Policy is active, then I’d gather information such as TFL, Mailing address, Payor ID and Reference number. My Final action would be to rebill the claim.

If the policy is inactive, I’d inquire whether there’s an active insurance policy for the patient. If yes, I’d ask for details about the active policy, including reference number. My final action would be to forward this information to the EVBV department.

If there’s no active policy, I’d request the reference number from the representative, and my final step would be to bill the patient.