MOCK CALL-Authorization Scenario
James is AR CALLER Calling from India to USA insurance live rep in order to check the claim status the rep’s name is Sandy.
James Dialed the number 899-862-3220 (United Health Care).
Sandy: Thanks for calling this is Sandy, how may I help you?
James: Hi, my name is James, I am calling for Doctor’s office and I would like to check the claim status of a patient
Sandy: Which Doctor’s office are you calling for?
James: I am calling for General Orthopedic associates
Sandy: What is your telephone number?
James: My telephone# is 800-999-9999
Sandy: What is the patient’s SSN (social security number)?
James: The SSN is 123-456-789
Sandy: Could you please hold for a moment so that I can pull the patient records?
James: Yes, please!
Sandy: What is the patient’s name and DOB?
James: The patient’s name is Linda Far and her DOB is 11-26-1995
Sandy: What is the DOS you checking for?
James: The DOS is 07-26-2020
Sandy: What is the billed amount on this claim?
James: The billed amount is $1500.00
Sandy: Could you please hold for a moment so that I can pull up the claim?
James: Yes Of course!
Sandy: Thanks for being on hold James the claim was denied?
James: Okay may I know the claim received date?
Sandy: The claim was received on 08-15-20203.
James: And what is the denial date?
Sandy: The denial date is 08-22-2020
James: May I know the reason for the denial?
Sandy: Claim was denied for no authorization on file!
James: Could you please hold for a moment; I will search for authorization?
Sandy: Okay!
James: Thank you so much for holding I really appreciate your patience! “Sandy I upon checking I cannot find any auth# in my system, can you please check whether any hospital claim was received on this DOS?
Sandy: Let me find that James?
James: Okay
Sandy: James I cannot find any hospital claim on this DOS
James: Can we get a retro authorization in this case?
Sandy: Sorry James retro auth is not possible!
James: Okay Sandy can we send an appeal?
Sandy: Yes you can!
James: What is the appeal address?
Sandy: Yes the appeal address is PO BOX 30432 SALT LAKE CITY UT 84130-0432!
James: What is the timely filing limit for appeal?Sandy: The TFL for appeal is 365 days from the date of denial!James: Okay what is the claim#?
Sandy: The claim# is 98745
James: And what is the call reference#?
Sandy: The call ref# is 8578.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye…
If the Place of service (POS) used is 23 in auth denial what will you do?
James: Thank you so much for holding I really appreciate your patience! “Sandy upon checking I found the POS we have used is “23” which denotes this is an “emergency service” so this couldn’t be denied as no auth on file, could you please check it?
Sandy: Let me check that James?
James: Okay
Sandy: James you are right, the POS you have used is 23 since this is an emergency service I am sending this claim back for reprocess and please allow 45 business days for the review!
James: Thank you so much, Sandy, what is the claim#?
Sandy: The claim# is 98745
James: And what is the call reference#?
Sandy: The call ref# is 8578.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye…
If auth# is found in your system now what will you do?
James: Thank you so much for holding I really appreciate your patience! “Sandy upon checking I found auth# in my system, can I verify that with you?
Sandy: Yes James go ahead?
James: Thank you and the Auth# is A8765432
Sandy: James can I put you on hold to verify it?
James: Sandy take your own time!
Sandy: Thank you, James!….James thanks for being on hold I verified and found the Auth# you have given is valid for this Dos.
James: Sandy can you please send this claim back for reprocess with this auth#Sandy: Okay let me take a note on it and send this claim back for reprocess!
James: Thank you!
Sandy: Thank you, James! I have sent it back for reprocess and please allow 45 business days for review.
James: Thank you so much Sandy what is the claim#?
Sandy: The claim# is 98745
James: And what is the call reference#?
Sandy: The call ref# is 8578.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye…
If Retro auth# is possible now what will you do?
James: Can we get a retro authorization in this case?
Sandy: Yes James retro auth is possible!
James: Okay Sandy how could we get the Retro authorization?
Sandy: Yes you can call the authorization department at 187-845-7892!
James: Okay what is the claim#?
Sandy: The claim# is 98745
James: And what is the call reference#?
Sandy: The call ref# is 8578.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye…
If you found PAYMENT for the same CPT code without authorization# in previous DOS now what will you do?
James: Thank you so much for holding I really appreciate your patience! “Sandy upon checking I found the same CPT code was paid previously without any authorization# can you please verify that?
Sandy: Yes James what is that previous DOS? James: The previous DOS is 01-22-2019Sandy: James can I put you on hold to verify it? James: Sandy take your own time!
Sandy: Thank you, James!….James thanks for being on hold I verified and found this CPT code was paid previously without any Auth#.
James: Sandy can you please send this claim back for reprocessing with reference to the paid claim?
Sandy: Okay let me take a note on it and send this claim back for reprocess!
James: Thank you!Sandy: Thank you, James! I have sent it back for reprocess and please allow 45 business days for review
James: Thank you so much Sandy what is the claim#?Sandy: The claim# is 98745James: And what is the call reference#?
Sandy: The call ref# is 8578.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye…
If the rep said HOSPITAL Claim was received on this DOS now what will you do?
14. James: Thank you so much for holding I really appreciate your patience! “Sandy I upon checking I cannot find any auth# in my system, can you please check whether any hospital claim was received on this DOS?
Sandy: Let me find that James?
James: Okay
Sandy: James I have found one hospital claim on this DOS
James: Okay Sandy can you please check any authorization# in that hospital claim?
Sandy: James yes I have found one AUTH# IN HOSPITAL CLAIM
James: Could you please send this claim back for reprocessing with that Auth#.
Sandy: James I can send but I am not guaranteed whether your claim will be payable or not!
James: That’s not a problem, Sandy, you can send it!
Sandy: Okay let me take a note on it and send this claim back for reprocess!
James: Thank you!
Sandy: Thank you, James! I have sent it back for reprocess and please allow 45 business days for review.
James: Thank you so much Sandy what is the claim#?
Sandy: The claim# is 98745
James: And what is the call reference#?
Sandy: The call ref# is 8578.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye…