1) ID /COVERAGE PROBLEM(ESI – 2)

Denial reasons:
• Coverage Terminated.
• Coverage Not in Effect.
• Patient cannot be identified.

Action:-
 First check the PD sheet to find out whether the id# and Patient name has been
entered correctly and card copy is given.
 Need to check in the patient ledger whether we received any payment or not .If
received need to check for the policy id#.
 Need to search Globally whether the patient exists in any other dataset. If yes need to
check that account whether payment is received for the consecutive dos. (Need to
check notes whether caller called?)(If the denial is patient cannot be identified need
to search with patient Last Name.)
 Need to check EDSS, AVAILITY, and WELLCARE. Whether the patient have any
other insurance falls in the category.
 Need to give for calling to check with the insurance. Whether any other information
found for the patient.
 Finally if the insurance details is not found. Need to bill the patient with the effective
date. (In PAY ADD Screen if Attorney info no given).

Notes:-

Checked dnl batch ______ pg# ___ dnd as ______. Checked Charge batch ____
Pg# ____ found the same. Searched globally pt not found in any of the dataset.
Checked online sites for eligibility no information, Checked Caller notes no
Information found, Hence billed the patient.

FYI: - If any of the information found, alter the above comments.

AR Screen. (Billing the Patient)

Followup date : - 30 days

Followup : - Patient
Action : - Bill Patient.
Error Created : - NA
Ar Status : - Resolved.
Workorder to : - No-One
2) Medical Records Needed (ESI – 3):-

 Need to Check the denial Eob for exact Records Needed.

 Need to Check the notes Whether we had sent any medical records and also need to
check whether we received Medical records for this dos.

 If medical records does not sent or received, Need to request medical records.(If
Medical records already sent to insurance need to call the insurance).

Notes:-

Checked dnl batch ______ pg# ______ dnd for medical records. Checked Notes
no ST6 or ESI notes regarding Medical records. Hence the Info request made and
Moved to ESI Supervisor.

FYI:- If any of the information found, alter the above comments

AR Screen.

Followup date :- 15 Days

Followup :- Client
Action :- Pending for Medical Records.
Error Created :- NA
Ar Status :- Medical Records Needed
Workorder to :- Esi Supervisor.

3) Not Medically Necessary.(ESI – 4)

Action:-

 Need to Check the denial Eob for exact Denial Reason.

 Need to Check the notes Whether we had sent any medical records and also need to
check whether we received Medical records for this dos.

 Need to check the cpt is paid before and also need to check whether it is a payable
code

 Need to check the Profile update and also the Charge Sheet whether the cpt is billed
correctly.

 If medical records does not sent or received, Need to request medical records.(If
Medical records already sent to insurance need to call the insurance).
 Notes:-

Checked dnl batch ______ pg# ______ dnd for medical records.Checked Notes
no ST6 or ESI notes regarding Medical records.Hence the Info request made and
Moved to ESI Supervisor.

AR Screen.

Followup date :- 15 Days

Followup :- Client
Action :- Pending for Medical Records.
Error Created :- NA
Ar Status :- Medical Records Needed
Workorder to :- Esi Supervisor.

4) Benefit Exhausted (ESI – 12):-

Action:-

 First Check the Denial batch whether the insurance dnd Correctly

 Need to check whether any other insurance found for the patient.If yes need to
 Bill the insurance else need to bill the patient(If Attorney details is not found)

Notes:-

Checked dnl batch ______ pg# ______ dnd for Benefit Exhausted.Checked
Policy details no other insurance Coverage found.Hence billed the patient.

AR Screen.(Billing the Patient)

Followup date :- 30 days

Followup :- Patient
Action :- Bill Patient.
Error Created :- NA
Ar Status :- Resolved.
Workorder to :- No-One
5) Resubmit to other Insurance (ESI -68):-

Action:-

 First need to Check the denial whether any other insurance information
given (Eg – Medicaid – 308)

 Need to follow the Ref#1 (Esi – 2 Coverage Id problem)

6) Down Coding Explanation (ESI – 32) :-

 Check the charge sheet as to whether the rejection is due to wrong keying in at the
time of charge entry.

 If yes, inform ESI to change and submit the correct code.

 If no then read the explanation that the insurance has given in the EOB for
Down-coding.

 If they have requested for additional documentation to substantiate the use of a

higher level code then inform ESI of the same with the details of the additional
records requested for the dos.

 If Medical records needed, follow the Ref#2 (ESI – 3)

7) Pre Existing Condition (ESI – 53).

 First , Need to check the EOB for the Pre – Existing condition information.

 Need to give for calling to check how many letters had been send to patient. If it is
more than 2 letters and if there is no response for the last letter, if it cross more
a month. Then we call bill the patient. If not need to wait till the time frame (If the
letter only before 20 days)

Notes:-

Checked Dnl batch _____ pg# ___ dnd for pre-existing condition.From
calling notes _2__ letters had been send to patient on ___ date , there is no
response from the patient,hence billed the patient.

AR Screen:-

Need to followup the Ref#1 (ESI – 2 Coverage) Screen.

8) Need Physician Signature(ESI – 37).

Action

 First need to check the eob for the denial reason.

 Move to ESI Supervisor for the further followup.

Notes:-
Checked dnl batch ____ pg#_____ dnd f or Physician Signature. Hence
moved to ESI Supervisor.

AR Screen.

Followup date :- 15 days

Followup :- Client
Action :- Action Needed From Different Department.
Error Created :- NA
Ar Status :- Action Required from ESI.
Workorder to :- ESI Supervisor.

8) Capitation(ESI – 20).

Action:-

 First need to check the client profile whether the Dr for the insurance is under
capitation.

 If the provider is not capitated need to check with the insurance regarding the
capitation agreement.

 If the all the above steps proves that the provider is capitated provider.Need to
adjust the charge.(Note:- For some dataset like GG need to change the MMRP 8 and
RP CP.)

 Need to update the charge entry regarding this to use MMRP 8.

Notes:-

Checked Denial batch _____ pg# ____ Insurance dnd this clm for capitation.
Checked Client Profile found the provider is capitated for the insurance from ______
.Hence the charge is adjusted.

AR Screen.
Followup date :- 15 days.
Followup :- Others.
 Action :- Adjust Charge.
Error Created :- NA.
Ar Status :- Resolved.
Workorder to :- No-One.
9) Invalid CPT or Modifier (ESI – 63):-

Action:-

 Check the charge sheet as to whether the rejection is due to wrong

keying in at the time of charge entry.
 If yes, inform ESI of the correct code to be use.
 If not, check if the code used is correct with EncoderPro, CCI Edits &
LMRP’s.
 If we have used a wrong code then inform ESI, so that they can
change it and refile the claim.
 If no then there is one more reason for getting this type of rejection, the
carrier may not be paying for some codes.
 In such cases request ESI to call the carrier and if the carrier says that
they do not pay for the procedure then the amount has to be written off.
 There are cases where the primary may not be paying for one code
whereas the secondary may consider the same (ex) Medicare wont
pay for dental procedures whereas a secondary Commercial may pay
for the same.
 In such cases request ESI to submit the claim to the secondary
insurance.

Template

Esi Denial code: 8

1. Per scan file --------- Page#--- (Insurance name) Denied stating that
Service not covered by (patient’s benefit plan / provider’s contract / Not clear).

3. If (Patient) Checked the note entry (If any notes available then) as per
previous called notes this particular CPT is not covered by patient’s Benefits Plan hence
billed.
 3. It (patient) Checked the note entry (If no notes available then) Hence
need to call insurance and check the patient’s benefits details.

4. If (provider) checked the note entry no notes are available and checked
the CPT description and this provider is eligible to do this service.

5. Hence need to call insurance and check the provider’s contract with that
Insurance.

6. (Denial not clear - Service not covered) Need to follow from Step1 , …
Hence call insurance and check whether this service is not covered by Patient’s Plan or
Provider’s Contract.

Template

Esi Denial code: 61

1. Per scan file -------- Page#--- (Insurance Company Name) Denied

stating that Referring Dr field contains Invalid Data.

2. (If referring Physician not selected in the Medenet) Per Medenet

referring physician not selected.

2. (If referring physician selected in the Medenet) Per Medenet referring

physician name selected as (Referring Dr. name)

3. (If referring physician name given in the charge scan file) checked the
original charge scan file -------- page#--- referring physician name given as (Referring
Physician name).

4. Checked the upinregistry.com and found that the UPIN number in our
referring physician master is correct.

5. Hence correct referring physician name selected and refilled the claims
to Primary insurance.
 3. (If referring physician name not given in the charge scan file) checked
the original charge scan file ------ page#--- referring physician details not given.

5. Referring physician details not found. Hence need to add the referring
physician and refile the claim to Primary Insurance. (ESI Supervisor)

Name: N.K. Senthil

Steps To be followed

Esi Denial code: 8

1. Check the denial scan file and ensure that the particular denial has been
captured for correct Patient, DOS, CPT and also the ESI denial.
2. If insurance denied as service not covered then there are only two options for
that.
a. Service not covered by Patient’s benefits plan
b. Service not covered by Provider’s contract.
3. First we should ensure whether this denial is belongs to patient’s benefits or
Provider’s contract.
4. Then we should check the note entry. If any called notes are then we can take
actions according to that.
5. If no notes are available then we should give this for calling and should make a
note of this CPT and Insurance for Future reference.

ESI Denial code: 61

1. Check the denial scan file and ensure that the particular denial has been
captured for correct patient, DOS, CPT and also the ESI Denial.
2. This denial mostly will come from Medicare and the denial code is M68.
3. First we should check whether in Medenet we have selected the referring
physician or not.
4. Then we should check the original charge scan file for the referring physician
details.
5. If we have a referring physician in charge file then make sure that the UPIN
number for that referring physician is correct or not by seeing the website
upinregistry.com.
6. If the UPIN number mismatch with our Medenet master and ESI Master and
we need to send a request mail to ESI stating that need to update or add a correct UPIN
number for this referring Physician.
 7. Many times Dummy UPIN number will appear in our Medenet Master. The
format for the dummy UPIN number is OTH000.In that time need to login to
upinregisry.com and get the correct UPIN number and send a mail to ESI to add the
correct UPIN number.
8. If could not able to find the referring physician in the charge scan file (Make
sure that should check all the possibilities) then we should not give this for calling.
Instead we should forward this account to ESI Supervisor stating that referring physician
not found hence need to add a correct referring physician with correct UPIN number and
refile the claim..

Duplicate Claim:

1. Chk the Status Details to know How Many time we filed the clm to INS.

2. If More then One Entry - Need to Chk the Note Entry for to know the RSN Why We
Refiled.

3. If the Line Item DND as Duplicate, We Need to chk Payment/Dnl - EOB of the Other
Line

Item in the DOS to find any Payment or Dnl for the Dnd Clm.

4. If we are not get any above info then Move the Clm to Call Center to Find the status of

the Original Clm.

DOS Incorrect:

1. Chk the Charge Scanfile to find the correct DOS.

2. If DOS IS correct in Charge scanfile, Then Chk the Billed Units for DOS.

3. If All above are correct then Need to Move the A/c to Call Center to Cross Chk the Dnl

RSN.
 1) Authorization/Referral problem

ESI Supervisor
A)Checked dnl batch__ pg#__ dnd as____. Checked superbill#____ pg#__
and Online (availity / amerigroup) sites no auth# found. No ESI notes for referral
form. Need to contact the PCP:____ @ _____ for referral#.

Refile
B)MCD denied stating service not authorized by medipass PCP, Checked
superbill# ----pg#--- PCP: --- @ --- found. Checked EDSS.com and verified the PCP
name. Hence refilled the clm with ref phy id# to MCD.

2)Coverage/ID problem

A) Checked dnl batch ______ pg# ___ dnd as ______ . Checked

Superbill ___ Pg# ____ found the same. Searched Globally pt not found in
any of the dataset. Checked online sites for eligibility no information. f Hence
billed the patient.

3)Medical Records

Checked dnl batch ______ pg# ______ dnd for medical records.
Checked Notes no ST6 or ESI notes regarding Medical records. Hence
the Info request made and Moved to ESI Supervisor.

4) Not Medically Necessary.(ESI – 4)

Checked dnl batch ______ pg# ______ dnd for medical records.
Checked Notes no ST6 or ESI notes regarding Medical records. Hence
the Info request made and Moved to ESI Supervisor.