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  • Ernest Sari

Revenue Cycle Management: Following up on Claims

Following up on your claims is an important step in the Revenue Cycle. This step usually involves calling the claims department of insurance companies and asking the representatives about the status of a claim that you have submitted beforehand.

Claims representatives will ask for the following:

- Patient's DOB

- Patient's ID number

- Patient's first and last name

- The Provider's NPI/TIN

- What state the services are rendered in

Once you provide this information it will be your turn to ask questions and make inquiries about claims you want to know the status of.

You will need to ask:

- What is the status of the claim?

- When is the claim scheduled for payment?

- Where in the payment process is the claim?

- Why is the claim taking so long to process?

- Why is the claim pending or under review?

- Where do I need to send medical records?

- Who can I speak with to get this claim paid faster?

- Why is the claim not being paid according to contract?

If the claim has been paid, you must ask for:

- The check number

- The issue date of the check

- Whether the check has been cashed or is still outstanding

- The amount of the check

- Whether the amount was paid to the provider or the member

If the claim was not paid, they can be denied for various reasons. Here are a few:

- No claim on file

- Medical records needed for further review

- Need primary insurance EOB information

- Information needed from the member/subscriber

- Prior authorization not on file

- Referral not on file

- Information on claim missing or invalid

- Need pre-existing information from primary care physician

- No medical necessity

- Accident details required

Following up on claims might seem like a daunting task at first, but as with anything else, it gets easier with time. You will be dealing with many different personalities on the phone which greatly affects the quality of the call. It is important to stay vigilant and be assertive when on the phone with representatives, which can help keep calls short and concise.

Another solution to help make following up a more manageable and time efficient task is to sign up for online access for the desired insurance companies. The initial set-up might take some time depending on the insurance company, but it will ultimately save more time in the long run.

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