OPEN CLAIMS MANUAL
PATIENT LISTS REMOTE DESKTOP CONNECTION ONE NOTE 8X8 DIALER STICKY NOTES
WHERE TO GET MONTHLY LISTS.
1ST STEP: OPEN EAGLE SOFT WITH YOUR OWN LOG-INS AND CLICK ON REPORTS AND INSURANCE
2ND STEP: CLICK OUTSTANDING CLAIMS BY INSURANCE COMP.
3RD STEP : CLICK PROCESS WHEN YOU SUCCESSFULLY CLICKED PROCESS YOUR LIST SHOULD COME UP AND ALL WE NEED TO DO IS PRINT IT.
WHERE TO LOOK WHEN YOU NEED INFORMATION ABOUT PATIENTS.
THE SYSTEM THAT WE ARE USING GIVES US A LOT OF ROOM TO KNOW EVERYTHING ABOUT THE PATIENTS. WE ALWAYS NEED TO UTILIZE IT. HERE IS HOW ; PATIENT SMARTDOC PATIENT NOTES
TO GIVE IT CLARIFICATION; SMART DOC GIVES YOU THE INFORMATION ABOUT THE ORIGINAL FEES FOR THE PATIENT'S PLAN, WHICH ALREADY INCLUDES EVERY CODE/PROCEDURE THERE IS. PATIENT NOTES GIVE YOU A BREAKDOWN OF EVERYTHING THAT IS WITH THE PATIENT'S PLAN. IF YOU WOULD NEED TO CHECK IF A CODE HAS ALREADY BEEN USED MULTIPLE TIMES IF YOU WOULD NEED TO CHECK THE PATIENT'S ID, ADDRESS, GROUP NUMBER, AND SPECIFIC INSURANCE. IN SIMPLE WORDS. EVERYTHING HAS BEEN HANDED OUT TO US, ALL WE NEED TO KNOW IS WE TAKE NOTE OF EVERY LITTLE DETAIL BECAUSE WITHOUT IT WE CAN'T BE ABLE TO PROCEED.
PROCESS OF CLOSING THE CLAIM
THERE ARE STEPS THAT WE NEED TO KNOW WHEN CLOSING THE CLAIM. -COMPARE THE EOB TO THE PATIENTS ACCOUNT IF THE AMOUNTS ARE MATCHING.
- IF YES: PROCEED TO CLOSE THE CLAIM AND ENTER THE TOTAL AMOUNT FROM THE EOB INTO THE "AMOUNT" SECTION ON THE TAB -- "INSURANCE PAYMENT" ON EAGLESOFT AND ALWAYS MAKE SURE THE "FINAL PAYMENT" HAS A CHECK MARK ON IT THEN CLICK SAVE.
IF NO: STILL PROCEED TO CLOSE THE CLAIM AND THE SAME INSTRUCTIONS APPLY. THE ONLY DIFFERENCE IS, YOU WILL NEED TO ADJUST THE AMOUNT TO HAVE BOTH AMOUNTS MATCH. WE WILL NEED TO ADJUST THE AMOUNTS AND WE CAN BE ABLE TO DO THAT BY GOING BACK TO THE "ACCOUNT" TAB ON EAGLE SOFT AND LOOK FOR THE SPECIFIC DATE OF SERVICE. 1 2 3
TAKE NOTES AND MAKE NOTES THIS IS ANOTHER PART THAT WE NEED TO DO AS OPEN CLAIMS, WE NEED TO TAKE NOTES AND MAKE NOTES TO THE ACCOUNT IN EVERY POSSIBLE DETAIL THAT NEEDS TO BE PUT ON EVERY PATIENT'S ACCOUNT. EXAMPLES ARE, IF THE ACCOUNT IS ON AN "HMO PLAN" , HAS "BREAKDOWNS ON PATIENT NOTES" , HAS "PATIENT RESPONSIBILITY/ DEDUCTIBLE" , FOR "RESUBMITTING" , AND HAS CODES THAT NEED TO TAKE NOTE OF.
DENIALS NEED TO KNOW
DENIALS WHEN IT COMES TO DENIALS, THERE ARE SOME THAT WE CAN'T DO ANYTHING ABOUT AND THERE ARE OTHERS THAT WE WOULD NEED TO RESUBMIT OR IN SOME OTHER TERMS WE NEED TO TAKE ACTION. OF COURSE, BEFORE WE TAKE ACTION ON CERTAIN CODES WE NEED TO DOUBLE-CHECK EVERYTHING ELSE BEFORE WE DO SO. EXAMPLES OF THOSE THAT WE CAN'T DO ANYTHING ABOUT ARE; - NOT A COVERED BENEFIT - SERVICE EXCEEDS MAXIMUM AMOUNT PER PERIOD (depending on the notes if the code had been exceeded) - ANNUAL MAXIMUM LIMIT HAS BEEN REACHED (p.s these are the ones that are common) ---- (-NEXT PAGE CONTINUATION)
EXAMPLES OF THOSE THAT WE HAVE TO TAKE ACTION FOR ARE; - PLEASE RESUBMIT WITH THE REQUIRED QUADRANTS - MISSING TOOTH CLAUSE. NO HISTORY OF EXT OF TOOTH - PENDING NEED TO SEND A COPY OF PREOPERATIVE XRAY - SERVICE PRE-AUTHORIZATION DENIED THERE ARE MORE DENIALS FROM WHERE THESE CAME FROM. IT IS BETTER TO ALWAYS DOUBLE, TRIPLE, QUADRUPLE CHECK IT BEFORE MAKING ANY CHANGES. SUCH AS WHETHER WE MAY NEED TO RESUBMIT THOSE DENIALS OR NOT. CLAIMS THAT HAVE DENIALS ARE THOSE FOR WHICH WE CANNOT CLOSE THE CLAIM. IF THE CLAIM OR A "CODE" HAS BEEN DENIED WE NEED TO TAKE NOTE OF THOSE AND PUT THEM ON THE SPREADSHEET THAT WE HAVE GIVEN YOU. AND WITH THIS PROCESS WE CAN MAKE RESOLUTIONS AS A TEAM.
RESUBMITTING CLAIMS
WE USE TWO TOOLS WHEN IT COMES TO RESUBMITTING CLAIMS. THOSE ARE; -REMOTE LITE -INSURANCE PORTAL THESE TWO OPERATE PRETTY MUCH THE SAME BUT THEY JUST LOOK DIFFERENT. WHEN WE RESUBMIT, WE HAVE TO TAKE NOTE OF THE CODES THAT WE ARE SUBMITTING, AS WELL AS THE AMOUNT. WE HAVE TO BE THOROUGH ENOUGH TO KNOW WHAT WE ARE RESUBMITTING BECAUSE IF WE DON'T, WE ALWAYS TEND TO ASK MORE THAN WHAT WE ALREADY KNOW.
EOBS NEED TO KNOW.
ALLOWED AMOUNT IS ALWAYS WHAT WE LOOK FOR IN AN EOB AND IT MAY COME IN OTHER TERMS SUCH AS; - CONSIDERED CHARGE - NEGOTIATED AMOUNT - ALLOWANCE THESE ARE SOME OF THE TERMS THAT WE WILL SEE WHEN OPENING THE EOB SENT TO US. ALLOWED AMOUNTS ARE WHAT WE COMPARE FROM THE EOB ITSELF TO THE PATIENT'S ACCOUNT. AS STATED ABOVE --(PROCESS OF CLOSING CLAIMS)
DENIALS ARE ALWAYS IN "RED" WE NEED TO TAKE NOTE OF THOSE DENIALS, FOR US TO UNDERSTAND THEM MORE THAN WE ONLY JUST SAW THEM A FEW TIMES. DEDUCTIBLES/PT'S RESPONSIBILITY-- THERE ARE SOME WITH AND THERE ARE SOME WITHOUT. WE NEED TO MAKE SURE TO TAKE NOTE OF THESE PARTS BECAUSE WE WOULD NEED TO PUT IT IN THE "PATIENT NOTES" ON EAGLESOFT AND AS WELL AS EMAIL IT TO OUR RESPECTIVE MANAGERS. (WHICH LEADS US TO OUR NEXT TOPIC)
FOR EMAILS WE HAVE A FEW THINGS THAT WE NEED TO REMEMBER. HERE ARE THE EXAMPLES; - D2950 - IF NOT A COVERED BENEFIT, EMAIL THE MANAGER TO COLLECT (ALWAYS) - IF THERE ARE DEDUCTIBLES IN THE PATIENT'S EOB MAKE SURE TO EMAIL IT. ALSO IF THERE ARE CODES THAT ARE NOT COVERED, INCLUDED THOSE ALSO. - WHEN THE PATIENT IS OUT OF THEIR LIMIT, WE NEED TO TAKE NOT OF IT FOR US TO EMAIL TO OUR RESPECTIVE MANAGERS. - WHEN THE DENIAL IS A DUPLICATE PROCEDURE WE NEED TO MAKE SURE TO CHECK ON THE PATIENT'S HISTORY AND THE PLAN TO CHECK. IF YOU HAVE CONFIRMED THAT IT IS INDEED A DUPLICATE, EMAIL THE MANAGER. IF IT IS NOT A DUPLICATE WE WOULD STILL NEED TO EMAIL THE OFFICE MANAGER FOR US TO BE ABLE TO KNOW WHAT IS OUT NEXT STEP OF THOSE DENIALS. (D09910 - EXAMPLE)
ALWAYS REMEMBER THAT WE HAVE TOOLS TO GIVE US WHAT WE NEED AT EVERY MOMENT. WE GOT THIS, OPEN CLAIMS! YOU WILL ALWAYS HAVE SUPPORT BY YOUR SIDE AND IS READY AND GLAD TO HEAR WHAT YOUR CONCERNS AND SUGGESTIONS ARE.