Summary

Claims Processing Workflow

Initiate claims processing by selecting either the Q claim or Manual Claim. Access the claim details via the claim hyperlink in the system, then extract the Claim Chart number for tracking. Retrieve patient details using the voucher number through the PMS Account Inquiry page.

Reviewing Claim Denials

To assess claim status, check the Account Ledger and service level views. If a denial is detected, specifically for code PR27 (expenses post-coverage termination), confirm eligibility via the organization’s validity portal. Input necessary details including billing provider and patient identification to validate status.

Communication with Insurance

Contact the insurance provider for clarification on claim status. Ensure to obtain the insurance contact number from the patient’s ID card (often found on the back). Prepare to provide relevant claim and reference numbers during the communication. Document all relevant information for follow-up.

Documentation and Follow-Up

Complete necessary documentation in the system following the conversation with insurance. Select denied codes and actions for reprocessing claims. Ensure all key points are noted and saved in the system. Update the claim’s status accordingly and establish necessary follow-up actions for resolution.

Turnaround Time

Expect claim reprocessing turnaround of 14 to 30 calendar days based on the standard procedures outlined.