Claim Review
Claim Review process
Index
Claim Review Flow Chart
Step 1: Claim Review Folder
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When a claim is OPEN or INACTIVE, first open the Claim Review Folder.
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Look for any review listed under Step 3.
Step 2: Open Relevant Reviews
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Double-click the relevant review.
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If there are multiple, repeat Steps 2–5 for each one.
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Note: Ignore status (Resolved/Unresolved) as it may not be accurate.
Step 3: Related Docs & Globe
Compare the Inbound Correspondence folder to the appropriate folder for each review type:
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Accident Review: Accident Questionnaire Letter (AQL)
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Other Insurance Review: Other Insurance Letter
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Pre-Existing / Rescission Review: APS Provider Records, MRSI Provider Records, Name/Address of Doctors-Pharm (Claims)
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Surgeon / Anesthesia Review: Custom Letter to Provider
Step 4: Investigation / Review Notes
Access freeform review updates by clicking Notes. Go to the correct folder for each review type:
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Accident Review → Accident Folder
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Other Insurance Review → Other Insurance Documentation Folder
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Pre-Existing / Rescission Review → Investigations Folder
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Surgeon / Anesthesia Review → General Notes Folder
Step 5: Contact Management
Scan the subject lines of activities in Contact Management for relevant calls.
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Look for any reference to a review ID or review type (e.g., Accident Review).
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Critical step: information provided by members over the phone cannot be found in AI.
Review Scripts
Communicating Claim Status
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Open Claims
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Say:
“The claim is still open because we have requested some information we haven’t received back yet.”
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Inactive Claims
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Say:
“The claim has been denied as inactive at this time because we didn’t receive the information we needed in order to process the claim. As soon as that information is submitted, we will reprocess the claim and a new EOB will be generated.”
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Pre-Existing Reviews
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Explaining the N&A Form
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Say:
“What we are needing is a form that lists the names and addresses of the doctors, specialists, and pharmacies the member has seen from [insert date] to present. This is related to a pre-existing review.”
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Explaining the Med Records Requests
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Say:
“What we are needing are medical records from [provider name(s) if authorized] from [insert date] to present in order to determine if the treatment the member received on [insert date] would be considered pre-existing according to the plan.”
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Explaining the MRS Authorization Requests
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Say:
“We are needing the member to return an authorization for the release of their medical records. Until the member returns it, we are unable to receive the records we need to close the review.”
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Accident Reviews
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Explaining the AQL
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Say:
“We are needing a form that gives more details regarding the injury that the member was treated for on [insert date].”
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Other Insurance Reviews
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Explaining the OI Letter to Members
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Say:
“It looks like we need to know if you or any of the dependents on the policy had any other insurance from [insert date] to [insert date].”
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Explaining the OI Letter to Providers
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Say:
“What we are needing is information regarding a possible other insurance policy from the member.”
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Rescission Reviews
Do not use the word “rescission” unless it has been approved.
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Explaining Rescissions to Members
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Say:
“It looks like your policy has been rescinded, which means your coverage has been revoked and you will be refunded for any premiums paid, minus any claims we paid for you. You should have received a letter detailing the reasoning for this rescission. Did you receive it?”
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Explaining Rescissions to Providers
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Say:
“The member’s policy has been rescinded, so their coverage has been revoked and it’s as if they never had coverage with us.”
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Documenting Claim Review Calls
Member Calls
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If caller is not the member or provider, verify authorization on file or obtain verbal auth.
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If obtained, note: “Verbal auth received from member – NAME”
Provider Calls
Do not provide names of other providers medical records are being requested from.
Refer to them only as “other providers.”