Summary

Claim Process Overview

Begin the claim process using the Encounter number in the SearchBox. Access Claim Details via the Claim hyperlink in Arms and copy the Claim Chart number. Utilize the PMS Account Inquiry page to obtain patient details by entering the voucher number, then click Account Ledger for voucher specifics. Switch to Service Level View to view all CPT codes related to that voucher. If a denial is posted, access the ERA by right-clicking the voucher and selecting View Select Remit History.

Denial Handling

Investigate denial reason (e.g., PR27, indicating coverage termination). Use Google to check CARC codes for descriptions. Verify patient eligibility with the relevant provider (e.g., Humana). Log into the eligibility portal, input the required details (organization, provider NPI, Tax ID, patient ID, and date of service), and submit to retrieve eligibility results. If denied, contact insurance for clarification based on the patient’s active status.

Documentation and Follow-up

Record all interactions with insurance reps, noting down reference and claim numbers, patient information, and the denial incident. Document any resolutions and actions taken in Arms and PMS including CPT codes and their statuses, ensuring to follow up on claims where necessary. Save all updates and set a follow-up date as required for resolved claims.