Cal

lopeni
ng:

Hi
,mynamei
s--
--
--
--cal
l
ingonbehal
foft
hepr
ovi
der
’sof
fi
cet
ocheckonacl
aim st
atus.

GetI
nsur
anceRep’
sName:

MayIhav
etheDat
eofdeni
al:

(
Ifpai
dthengetCl
aim Pr
ocessedDat
eorPai
ddat
e)

Hol
dPr
ocedur
e:“
MayIpl
acet
hiscal
lonhol
dforamoment
?”

Hol
drel
ease:
“Thanky
ouf
orst
ayi
ngonl
i
ne”(
Uset
her
ep’
sname)
.

MayIhav
etheCor
rect
edcl
aimsmai
l
ingaddr
essorFaxnumberwi
that
tent
iont
o:

MayIhav
etheCor
rect
edcl
aimst
imel
yfi
l
ingl
i
mit
:

(
Or)

MayIhav
etheappeal
’
smai
l
ingaddr
essorFaxnumberwi
that
tent
iont
o:

MayIhav
etheappeal
sti
mel
yfi
l
ingl
i
mit
:

Forcodi
ngdeni
als:
For
war
dcl
aimt
ocodi
ngdepar
tment

(
1.I
fchangesr
equi
ret
henwi
l
lchangeandsubmi
tascor
rect
edcl
aim)

(
2.I
fnochangesmadebycoder
s,t
henappeal
thecl
aim wi
thmedi
cal
recor
ds)

MayIhav
ethecopyofEOB:

MayIhav
etheCl
aim number
:

MayIhav
etheCal
lref
erencenumber
:

Cal
lcl
osi
ng:
Thanksmuchf
ory
ourassi
stance,
youhav
eagr
eatday
.
*
PNOF:
*

[Link]
heRept
odoasear
chwi
tht
hepol
i
cyI
D.

_
(Reconf
ir
mthepol
i
cy#)
_

2.I
fthepat
ientwasnoti
dent
if
ied:

_
Requestr
ept
odoaPat
ientName& DOBsear
ch.
_

3.I
fthepat
ientwasst
il
lnoti
dent
if
ied:

_
Requestr
ept
odoaI
nsur
edname&DOBsear
ch.
_

4.I
fthepat
ientwasnoti
dent
if
iedi
nthename&DOB sear
cht
hen:

_
Requestt
heRept
odoanSSNsear
ch.
_

(
Pref
erencet
oPt
'sSSN&t
henI
nsur
ed'
s)

5.I
fpat
ientf
ound,
*col
l
ectt
hecor
rectpol
i
cy#&el
i
gibi
l
ityf
rom t
her
ep.
*

[Link]
heCLM st
atus(
Pur
poseoft
hecal
l
).

[Link]
lref
#

CLM dndf
orPr
im EOB:

[Link]
etheDODpl
ease?

[Link]
hepr
imar
ypay
oront
heDOS?

*
IfCi
gnawasf
oundt
obepr
imar
ypay
oronDOS,
then*

Sendt
hecl
aimf
orr
epr
ocessi
ng

Andgett
heF/
Udat
e.

*
Buti
fCi
gnawasn'
tthepr
imar
yonDOS,
then*

[Link]
ethepr
imar
ypay
er'
sinf
o-I
nsname&ph#&pol
i
cyI
D#

[Link]
'
vet
hemai
l
ingaddr
esst
osendt
hepr
imar
yEOB?

[Link]
'
vet
het
imel
yfi
l
ingl
i
mitt
osubmi
tthepr
imar
yEOB?
[Link]
dyoupl
easef
axmeacopyofdeni
edEOBpl
ease?

[Link]
'
vet
heCl
aim#&Cal
lRef
#.

*
:CLM pai
dtopr
ovi
der
:

[Link]
'
vet
hepr
ocessed&pai
ddat
epl
s?

[Link]
'
vet
heAl
l
owedamt
,pai
damount
,pat
ient
'
sresponsi
bil
i
ty&conadj
ont
hecl
aim pl
s?

[Link]
hemodeofpay
mentpl
ease?

3a.*
Pai
dvi
acheck*

✓MayI
'
vet
hecheckdat
epl
s?

✓MayI
'
vet
hechecknumber
?

✓Coul
dyout
ell
mei
fitabul
korsi
ngl
echeck?

✓I
fbul
k;Coul
dyoupl
stel
lmet
heamountont
hecheck.

_
Checki
ssuedwi
thi
n30day
s,t
henneedt
oal
l
owsomemor
eti
mef
ort
hecheckt
oreachus.
_

_
Checki
ssuedat
eismor
ethan30day
swhenwecal
l
,thenneedt
ogetencashmentdet
ail
s_

✓Coul
dyoupl
shel
pmet
oknowi
fthewascashedornot
?

_
Ifcashed_

✓MayI
'
veacopyofcancel
l
edcheckpl
s?

_
Ifnotcashed_

✓Coul
dyoui
ssueast
oppay
mentandi
ssueanewcheckpl
ease?

✓MayI
'
vet
hef
oll
owupdat
e?

3b.*
Checkpai
dvi
aEFT*
:

✓MayIknowEFTdat
e?

✓MayI
'
vet
heEFTnumberpl
s?

✓MayIknowi
ftheEFTwasbul
korsi
ngl
e?

✓MayI
'
vet
heamountont
heEFT?
3c.*
CLM pai
dvi
aVCC:
*

✓MayIknowt
hecar
dissuedat
e?

✓MayI
'
vet
hecar
dnumber
?

✓MayI
'
vet
heamountont
hecar
d?

✓Coul
dyoupl
shel
pmewi
tht
heCVV/secur
it
ycode?

✓MayI
'
vet
heexpi
rat
iondat
eont
hecar
d?

[Link]
dyoupl
easesendmet
hecopyofEOBv
iaf
ax?

[Link]
'
vet
hecl
aim number&cal
lref
erencenumberpl
s?

*
:CLM Pai
dtopat
ient
:

[Link]
'
vet
hepr
ocessed&pai
ddat
epl
s?

[Link]
etheAl
l
owedamt
,pai
damount
,pat
ient
'
sresponsi
bil
i
ty&conadj
ont
hecl
aim
pl
ease.

[Link]
hecl
aim waspai
dtopat
ient
?

*
Ift
hecl
aim waspai
dtoPtcosofPr
ovi
derbei
ngnonpar-Gi
vet
hePI
N#GA187*

Andr
equestr
ept
orepr
ocesst
hecl
aim

&

gett
hef
oll
owupdat
e.

*
Ift
hecl
aim waspai
dtoPtcosofAOBnotsi
gnedt
hen,
*

[Link]
'
vet
hecopyofEOB?

[Link]
'
vet
hecl
aim number&cal
lref
erencenumberpl
s?

*
:CLM dndasPr
ovi
derNonPar
:

[Link]
'
vet
hedat
eofdeni
alpl
s?

[Link]
vet
hePI
N#GA187t
orepandr
equestf
orr
epr
ocessi
ng.

*
ifr
epi
snotr
epr
ocessi
ngt
hecl
aim becauset
hePI
Nisnotv
ali
d,t
hen*

[Link]
'
vet
hev
ali
dit
yoft
hePI
Npl
s?
(
Chki
ftheDOSi
swi
thi
nthecont
ractper
iod,
thenr
equestr
ept
orepr
ocesst
hecl
aim)

*
ift
heDOSi
sbey
ondoraf
tert
hecont
ractper
iod,
then*

[Link]
sthePt
'spl
ant
ype?

(
IfPThasapl
ayt
ypeot
hert
hanHMO,
thenr
equestt
orepr
ocesst
hecl
aim andgetaF/
Udat
e).

*
ifPt
'spl
ani
sHMO,
then*

[Link]
l
ectt
hecopyofEOB.

[Link]
heCl
aim#&Cal
lref
#

*
:CLM dndasNonCVDScv
s:

[Link]
'
vet
hedat
eofDeni
alpl
s?

[Link]
dyoupl
easet
ell
mewhatar
etheser
vicesnon-
cov
ered?(
PX&DX)

[Link]
heser
vicesar
enon-
cov
d,i
sitbecauseoft
hept
'spl
anorpr
ovi
der
's
cont
ract
?

_
Ifi
tisbecauseofpr
ovi
der
'scont
ract-Col
l
ectt
heappeal
sdet
ail
s._

[Link]
heappeal
smai
l
ingadd/f
ax#&at
tent
iont
o?

[Link]
etheappeal
sti
mel
yfi
l
ingl
i
mit
?

[Link]
dyoupl
sfaxmeacopyofEOB?

[Link]
'
vet
hecl
aim #andt
hecal
lref#.

*
Postcal
l
:*

➡_ I
fthescv
sarenonCVDduetoPt
'spol
i
cy,
thenbi
l
lpat
ient/f
wdt
heacctt
oPtcal
l
ingdeptt
o
cont
actPt/escal
atet
ocl
i
ent
._

➡_
Ift
hescv
sar
edndduet
opr
ovi
der
'scont
ract
,thenappeal
oft
hecl
aim.
_

*
:*Cl
m dndasPr
im pai
dmor
ethansecondar
yal
l
owabl
eamt
:*

[Link]
'
vet
hedat
eofdeni
al?

[Link]
im haspai
d?

[Link]
'
vey
oural
l
owabl
eamountf
ort
hispr
ocedur
e/cl
m?
_
Chki
f*Pr
im pai
dAMT*i
sreal
l
y*mor
ethant
hesecondar
y'
sal
l
wdAMT*
_

_
Ify
es,
then_

[Link]
dyoupl
easef
axmeacopyofEOB?

_
Ifno,
then_

[Link]
dyoupl
easer
epr
ocesst
hecl
m asy
oural
l
wdamti
snotmor
ethant
hepr
imar
ypai
damt
?

_
MayI
'
vet
hef
/udat
epl
ease?
_

[Link]
'
vet
hecl
m#&cal
lref
#?

*
:*CLM pr
ocessedt
owar
dsCapi
tat
ion:
*

[Link]
'
vet
hepr
ocesseddat
e?

[Link]
dyoupl
easet
ell
mei
ftheser
vicesbi
l
ledont
hecl
aim ar
ecapi
tat
ed?

_
Ifnotcapi
tat
edser
vices,
thensendt
hecl
aimf
orr
epr
ocessi
ng.
_

[Link]
hecapi
tat
ionper
iodoft
hepr
ovi
der
?

_
Chki
ftheDOSf
all
swi
thi
nthecapi
tat
ionper
iod,
ifno;
thensendt
hecl
aimf
orr
epr
ocessi
ng.
_

[Link]
hePt
'spl
ant
ypepl
ease?

_
IfPt
'spl
ani
sot
hert
hanHMO,
thensendt
hecl
aimf
orr
epr
ocessi
ng.
_

*
Ift
hepl
ant
ypei
sHMO,
then*

[Link]
dyoupl
easef
axmet
hecopyofEOB?

[Link]
'
vet
heCLM#&cal
lref
#

*
:CLM i
nPr
ocess:

[Link]
ethecl
aimr
ecei
veddat
epl
ease?

[Link]
sthenor
mal
processi
ngt
imeofacl
aim?

*(
Calcul
atethenor
malpr
ocessi
ngti
mefr
om t
hedayi
nsur
ancehasr
cvdt
hecl
aim -checki
f
we'v
ecurrentl
ycal
l
edwit
hinoraf
ter
)*

*
Ifdel
ayed:
*
[Link]
her
easonf
ordel
ayi
npr
ocessi
ngpl
ease?

*I
ftheprocessi
ngi
sdel
ayedduet
oaddi
ti
onal
inf
ormat
ionneeded;
thenneedt
ofol
l
owt
hat
scenar
io*

*
Fort
her
estoft
her
esponses*

[Link]
ethef
oll
ow-
updat
epl
ease?

[Link]
ethecl
aim #&cal
lref
#

*
:*CLM pr
ocessedt
owar
dsdeduct
ibl
e:*

[Link]
'
vet
hepr
ocesseddat
epl
s?

[Link]
'
vet
heAl
l
owedamtpl
s?

[Link]
rom t
hegi
venal
l
owedamounthowmuchi
sappl
i
edt
owar
dspat
ient
'sdeduct
ibl
e?

_
IfAAi
snotequal
toDEDamt
,then_

✓MayIknowt
hest
atusoft
her
emai
ningbal
anceoft
heal
l
owedamountpl
ease?

*
(Col
l
ectt
hei
nfor
mat
ion)
*

_
IfAAi
sequal
toDed,
then_

[Link]
ftheCLM waspr
ocessedi
n-net
wor
korOON?

[Link]
het
otal
deduct
ibl
eamountasperpat
ient
'spol
i
cy?

[Link]
ienthassat
isf
iedt
il
ldat
e?

[Link]
fthepol
i
cywasannual
orl
i
fet
ime?

_
Ifpr
ovi
derwasani
n-net
wor
kpr
ovi
derandCLM pr
cdasOON_

*
OR*

_
Ift
heCLM waspr
cdi
ncor
rect
lyasDED,
wher
epat
ienthasmett
heDEDal
ready
_

t
hen

✓Coul
dyoupl
easer
epr
ocesst
heCLM?

✓MayI
'
vet
hef
oll
owupdat
e?

[Link]
dyoupl
easesendmet
hecopyofEOBv
iaf
ax?
[Link]
'
vet
hecl
aim number&cal
lref
erencenumberpl
s?

*
:*CLM pr
ocessedt
owar
dsOf
fset
:*

[Link]
'
vet
hepr
ocesseddat
e?

[Link]
l
ectpay
mentdet
ail
s(AA,
Amtappl
i
edt
owar
dsof
fset
,Pt
'sr
esp&conadj
)

_Plschkift
heOf
fsetamtandsai
dtopayamti
sequal
,i
fnotequal
gett
her
emai
ningbal
ance
status.
_

[Link]
'
vet
heov
erpai
dcl
aim'
sdet
ail
spl
ease?

*
Over
pai
dcl
msPt
'saccountnum,
DOS,
BA&amountov
erpai
d.*

[Link]
'
veacopyofCOMPLETEorawhol
eEOBv
iaf
ax?

[Link]
'
vebot
hov
erpai
dandof
fsetcl
aim'
snumber
s.

[Link]
'
vet
hecal
lref#f
ort
hiscal
lpl
s.?

*
:*Cl
m dndasi
ncl
usi
ve:
*

[Link]
'
vet
hedat
eofdeni
al?

[Link]
'
vet
hecodet
hati
sdeni
ed?

[Link]
thwhi
chpr
imar
ycodei
tisdeni
edasi
ncl
usi
ve?

_Idoseet
hatamodi
fi
eri
sal
l
owedasperNCCIedi
tshowev
erIwi
l
lconsul
twi
thmyCodi
ng
depar
tmentont
hesame.
_

[Link]
'
vet
hecor
rect
edcl
aim'
smai
l
ingaddr
ess&TFL?

&

[Link]
sohav
etheappeal
'
smai
l
ingaddr
ess&TFL?

[Link]
'
vet
hecopyofEOB.

[Link]
'
vet
hecl
m#&cal
lref
#

*
:*Cl
m dndasmaxi
mum benef
it
shasbeenmet
:*
[Link]
'
vet
hedeni
aldat
e?

[Link]
hert
henumberofv
isi
tsordol
l
arsgotmaxed?

[Link]
sthemaxi
mum dol
l
ar/
maxi
mum v
isi
tal
l
owedasperpat
ient
'spol
i
cy?

[Link]
ientmett
hemaxi
mum v
isi
t/dol
l
ars?

[Link]
dyoupl
easesendt
heEOBt
hroughf
ax?

[Link]
'
vet
hecl
aim#andcal
lref
#?

*
:*CLM dndasMedi
cal
l
ynotnecessar
y:*

[Link]
'
vet
hedat
eofdeni
al?

[Link]
chcode(
PX&/DX)i
sdeni
edasmedi
cal
l
ynotnecessar
y?

3a._
"AspertheLCDpolicyI
D#A56615,theser
vicer
ender
edt
oPti
smedi
cal
l
ynecessar
yso
coul
dyoupleaserepr
ocessthecl
aim?
"_

[Link]
dyoupl
sgi
vemet
heF/
Udat
e?

*
Ifr
epi
snotaccept
ingf
orr
epr
ocess,
thencol
l
ectt
heappeal
smai
l
ingaddr
essandTFL*

[Link]
'
vet
hecopyofEOB.

[Link]
'
vet
hecl
aim #&cal
lref#.

*
:*CLM dndasPXi
nconsi
stentwi
tht
heDX:
*

[Link]
'
vet
hedat
eofdeni
al?

[Link]
chPXi
sinconsi
stentwi
tht
heDX?

3._"
However,
thePXandDXi
srel
atedt
ocat
aractwhi
chexpl
ainst
heconsi
stencysocoul
dyou
repr
ocesst
heclai
m?"
_

[Link]
'
vet
heF/
Udat
e?

*
Ifr
epi
snotaccept
ingf
orr
epr
ocess,
thencol
l
ectt
heappeal
smai
l
ingaddr
essandTFL.
*

[Link]
'
vet
hecopyofEOBpl
s?

[Link]
'
vet
hecl
aim #&cal
lref#.
*
:*Cl
aim deni
edassubmi
tt
edi
nfor
mat
ioni
sinv
ali
dori
ncor
rect
:*

[Link]
ethedat
ethedeni
al?

[Link]
nfor
mat
ioni
sinv
ali
dori
ncor
rect
?

3.I
sthedeni
edi
nfor
mat
ioni
nval
i
dori
ncor
rect
?

_
Ift
he*
inf
ormat
ioni
sinv
ali
d*,
then_

_
MayI
'
vet
hev
ali
dit
yoft
hati
nfor
mat
ionpl
ease?
_

(
Chki
four*
DOSf
all
swi
thi
nthev
ali
dit
yper
iod*
)

_
Ify
es,
thenr
epr
ocesst
hecl
aim &gett
heF/
Udat
e._

_
Ift
he*
inf
ormat
ioni
sincor
rect
*,t
hen_

_
MayI
'
vet
hecor
rect
edcl
aim'
smai
l
ingaddr
essandTFLpl
ease?
_

[Link]
dyoupl
easesendmeacopyofEOBv
iaf
ax?

[Link]
'
vet
heCLM#&cal
lref
#

*
:*Cl
m dndasPr
im pai
dmor
ethansecondar
yal
l
owabl
eamt
:*

[Link]
'
vet
hedat
eofdeni
al?

[Link]
im haspai
d?

[Link]
'
vey
oural
l
owabl
eamountf
ort
hispr
ocedur
e/cl
m?

_
Chki
f*Pr
im pai
dAMT*i
sreal
l
y*mor
ethant
hesecondar
y'
sal
l
wdAMT*
_

_
Ify
es,
then_

[Link]
dyoupl
easef
axmeacopyofEOB?

_
Ifno,
then_

[Link]
dyoupl
easer
epr
ocesst
hecl
m asy
oural
l
wdamti
snotmor
ethant
hepr
imar
ypai
damt
?

_
MayI
'
vet
hef
/udat
epl
ease?
_

[Link]
'
vet
hecl
m#&cal
lref
#?