Claim Status Call Script

CLAIM STATUS CALL SCRIPT ═══════════════════════════════════════ BEFORE THE CALL ═══════════════════════════════════════ Have ready: - Patient name and date of birth - Member ID and group number - Claim number ([CLAIM_NUMBER]) - Date of service ([DATE_OF_SERVICE]) - CPT code(s) and total billed amount - Submission date and clearinghouse confirmation Open a call log entry. Record the call start time. ═══════════════════════════════════════ OPENING ═══════════════════════════════════════ "Good [morning/afternoon], this is [YOUR_NAME] calling from [PRACTICE_NAME] for a claim status check. Member ID is [MEMBER_ID]. The patient is [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME], date of birth [PATIENT_DOB]. The claim number is [CLAIM_NUMBER], date of service [DATE_OF_SERVICE], for CPT [CPT_CODES], total billed [BILLED_AMOUNT]. May I have your name and a reference number for this call?" → Record: representative name, call reference number, date and time. ═══════════════════════════════════════ PRIMARY REQUEST ═══════════════════════════════════════ "Can you confirm the current status of this claim, including any hold codes, pend reasons, or adjudication decisions?" If the claim is in adjudication: "What is the specific adjudication stage, and what is the expected payment or decision date?" If the claim has a hold or pend code: "What is the specific hold or pend code, what action is required to resolve it, and is the resolution on the payer side or the provider side?" If the claim has been processed: "Please confirm the allowed amount, paid amount, patient responsibility, and any CARC or RARC codes returned. When was the EOB issued and to what address?" ═══════════════════════════════════════ "IN ADJUDICATION" VS "DENIED" ═══════════════════════════════════════ If the representative says the claim is "in process" or "in adjudication": "How long has the claim been in adjudication, and what stage is it at? Per [PAYER_NAME] prompt-pay requirements, claims should be processed within [PROMPT_PAY_DAYS] days. The claim was submitted on [SUBMISSION_DATE], which is now [DAYS_OUTSTANDING] days outstanding." → If outstanding more than 30 days, escalate. Request a supervisor and ask for the prompt-pay policy in writing. If the representative says the claim is "denied" without a CARC code: "Please provide the specific CARC and RARC codes from the EOB, and confirm the appeal deadline. If the EOB has not been issued, when can I expect it, and to what address?" ═══════════════════════════════════════ EOB NOT RECEIVED ═══════════════════════════════════════ If the EOB or remittance was not received: "The EOB for this claim has not been received at our office. Can you reissue it to [PRACTICE_FAX] or to the practice address on file? Please also confirm the original mail-out date and the payment status. I'd like to verify whether the payment was issued and to what address." → Document the reissue request, the date promised, and the representative name. Calendar a 5-business-day follow-up. ═══════════════════════════════════════ ESCALATION TO PROVIDER RELATIONS ═══════════════════════════════════════ Escalate to provider relations when: - The claim has been in adjudication more than 30 days with no specific stage - A hold code cannot be explained or resolved by the front-line representative - A pattern of similar denials or holds appears across multiple claims for the same payer - Payment was issued to a wrong address or wrong entity "I would like to escalate this to provider relations. Can you provide a direct phone or email for our provider relations representative, and a reference number for this escalation?" ═══════════════════════════════════════ AFTER THE CALL ═══════════════════════════════════════ In the call log, record: - Call reference number - Representative name and department - Claim status, hold codes, expected resolution date - Action items (resubmission, corrected claim, appeal, follow-up) - Next follow-up date If the call did not produce a resolution, document the next contact point and the date.