Introduction

(Applause from seminar ending; seminar crowd background ambience)

Office biller (Biller): Thank you. That was a great presentation. Can I get your help on something?

Provider Representative (Rep): Certainly! What’s the issue?

Biller: I’m having trouble getting responses from the insurance companies. I need them to pay or deny, or do something, so I can send the claim on to Medicaid last.

Rep: So, you send in the claim – no response. Have you called up their customer service center?

Simple Re-file

Biller: Of course. One company said they never received the claim. So, I re-filed.

Rep: Did you take any extra measures like stamping the claim as a repeat submission or sending a cover note.

Biller: I sent a cover note, hoping that would help.

Rep: Did it get resolved yet?

Insufficient billing

Biller: Well, on that same one, I didn’t get a response for a while, so I called up again.

Rep: Did they receive it this time?

Biller: This time, yes, but… (Shyly) well, they said they considered the billing insufficient. I looked into it, and yeah, I forgot some things, so I sent additional information in that they requested.

Rep: Well, that’s good. I would keep up with that particular company since you haven’t been getting responses. Confirm with them that they’ve gotten all the information they requested and that you sent.

Non-responsive

Biller: OK, but that’s not worst of it. I have another situation. This other company didn’t respond, so I called them. They said that they did get my claim, they consider the billing valid, but…

Rep: But…?

Biller: But they haven’t suspended the claim yet.

Rep: What’d you do?

Biller: I made a note that they said the claim was valid. And I wrote them a follow-up letter asking them to send me a response on the claim’s outcome. That was yesterday.

Rep: OK, that was good. The next thing you should do is give them two weeks. If you haven’t seen anything, write them again citing your attempts to get an official response on this claim. And…copy the South Carolina Department of Insurance Consumer Division on your letter.

Biller: If that’ll help.

Rep: If not, you can send Medicaid your claim along with the Reasonable Effort Documentation form. It has you explain to us your attempts to get a response. That would be your last resort, if you exhaust all other options.

Closing

Biller: I appreciate your help. Hey, is that a flowchart of what we’re talking about?

Rep: Yes, it’s a quick reference tool to guide you if this happens again later on.

Biller: Thanks again!

Rep: You’re welcome!

Outro (5 sec)

(Seminar crowd background ambience)

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