ASHFAQ KHAN

CLAIM ASSESSMENT

⦁ Claim received online format after indexed by indexing team.
⦁ Check the membership id, Member name, status of policy (Active, Suspended, Inactive)
⦁ Seek the details on software as per received invoice like Provider details whether Practitioner, Hospital, Clinic etc along with specialization of the department.
⦁ Select the mode of payment i.e. Check or Electronic fund transfer.
⦁ Putting the Invoice no., Invoice date invoice currency
⦁ Seek the diagnosis code on google in icd10 format as per given on invoice we received.
⦁ Analyses the invoice whether it is one line service or multiple line service.
⦁ Putting allowed amount of invoice.
⦁ Select the CPT (Current procedure terminology) as per service given on invoice.
⦁ Validate the claim and get it finalised.
⦁ If there is any missing information which is necessary for adjudication should request before get it finalised.
⦁ Validate EOB (Explanation Of benefit) to the patient that is summary of Claim.

• Works as Senior Analyst in Credit Team for US Healthcare - Service Provider.
• Identifying the reason of credit from received accounts, and get it resolved by taking appropriate action.
• If patient made overpayment against the PR (Patient Responsibilities), check the open balance or Bad debt and refund to patient.
• If Insurance made overpayment or over adjustment in any accounts, get it resolved by taking appropriate action.
• Follow up with Insurance to get the status of any accounts like COB, claim denied for any reason etc.

• Check the appeal letter sent by policyholder wether it is valid appeal or not valid.
• Review the medical documentation and claim history of patient with the 180 days from the appeal received date.
• Read the policyholder policy and business guidelines to pay possible benefits if the claims was incorrectly denied or something was missed to pay earlier.
• If the claim is still going to be denied send denial letter to policyholder having verbiage of policy why claim is denying.
• Address all the concern policyholder has mentioned in the letter though X note if claim is going to be paid.
• Key all the possible benefits in CPS system to make the payment to policyholder.
• Expert in handling policies like Line of business - Hospital Indemnity, Hospital sickness, Accident policies.