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Claim Status

A step by step guide on managing claim inquiries and statuses

Index

  1. Claims Status Flow Chart

    1. Step 1: Collect & Verify Member Information

    2. Step 2: Collect Claim Information

    3. Step 3: Provide Claim Number & Receive Date

  2. Has the Claim Processed - Script
  3. Documenting the Ticket

Claims Status Flow Chart

To be used when managing a claim status ticket. Reference the Claim Status Playbook.

Check AI first for the claim once the caller authorization has been completed. 

Step 1: Collect & Verify Member Information

  • Ask:

    “What is the member’s ID number?”
    “May I have the member’s name and date of birth?”

Step 2: Collect Claim Information

  • Ask:

    “What was the date of service and billed amount for this claim?”

Step 3: Provide Claim Number & Receive Date

  • Say:

    “I was able to locate the claim. Would you like the claim number?”
    “It looks like this claim was received on [insert date].”


*If you cannot find the claim, make sure you are in the right policy. Next, 1) verify the information again and check the Zelis Claims portal. If it’s not there, 2) advise the claim is not on file, and 3) provide the claims mailing address and payor ID.*

Has the claim processed - Script

✔ YES

X NO

STEP 4:

PROVIDE PROCESS DATE

“This claim was processed on [insert date].”

>This is listed on the EOB.

STEP 4:

ADVISE CLAIM IS OPEN AND PROCESSING

“It looks like this claim is still being processed.”

STEP 5:

EXPLAIN EOB

“This claim was discounted $---, the member’s responsibility was $--, and the plan paid $--.”

**For providers, you may have to check Zelis and provide payment info.

STEP 5:

CHECK FOR DELAYS

  1. Open Claim Reviews
  2. Read through review “Investigation”notes.
  3. Check documents to see if missing information has been received.

STEP 6:

FAX OR EMAIL EOB IF REQUESTED

“What email or fax number can I send this claim to for you?” - OR - “All your EOBs are available online.”

STEP 6:

ADVISE TO ALLOW MORE TIME

“Our claims typically take 30-45 business days to process once we have all requested information.

*If the claim has been “Settled” for a week or more, but no EOB has generated, open CM to Claim

Documenting the conversation and closing the ticket

Throughout the call take notes on the ticket and log outcomes/interactions. Use the Claims Status Playbook for this step by step guide and resources. 

If documentation is required provide the documentation to the caller via email, send the email directly in the ticket with the attatched file. 

Close the ticket only when the claim status is completed.