This email is to inform you of the new policy and changes that we have implemented for the SOP Program for our department. To ensure that we are able to continue to provide the most remarkable patient experience, in every dimension, every time. The new SOP policy will take effect on October 14, 2014.
To provide you the needed information please log onto the internal MySite portal and follow the provided instructions. To access the information from outside the NH facility, log onto the external Mysite portal. These procedures are available in my office.
I look forward to your cooperation moving forward as we implement these new procedures. Please reach out to your supervisor and team lead with questions as they arise.
Anthony D. Graham, Patient Account Representative -Manager
Attachment: Procedures for completing Standard Operations Procedures
Procedures for Completing Standard Operation Procedures
I. Terms and Definitions
a. Denial code 11 means the diagnosis is Inconsistent with the procedure. b. DX = diagnosis
c. EOB = Explanation of Benefits
d. PAR = Patient Account Representative
e. WQ = Workqueue
f. Coder = Person who is certified to review and change procedure codes, diagnosis codes and units. g. Reference Number = Number given by insurance
company which documents your phone call.
Read all notes in Account notes and Transaction History regarding the DOS Ensure the claim is not in the coding WQ being reviewed
If the claim is not currently in the coding WQ, note the account and transfer the claim to the Coder. Click on the “Transfer” icon with a red arrow
In the “work queue” field click add the Coder’s WQ number Add a note in the “comment” field
If the claim had If the claim has already been reviewed by coding department and rebilled to the insurance company with a different diagnosis code (allow 30 days to process) , call the payor for the updated claim status (see section V) and note the account (see section IV) defer 15 days Defer 15 days
From the assistant click the “Defer” icon on the tool bar
In the” Defer to date” type( T+15 )(# of days to be deferred)
In the message box type the reason for the deferral
a. Denial Code Dictionary
b. Notes Template
Where to go:
A. If you transferred the claim to the coder, use this note example: DOS: XX/XX/XX. Per (Payor’s Name) EOB, the claim denied because the DX was inconsistent with the procedure. Transferred the claim to the coder (WQ #_____) for review. B. If you had to call the payor, use this note example:
DOS: XX/XX/XX. Per (Payor’s Name) EOB, the claim denied because the DX was inconsistent with the procedure. Called (Payor’s Name) at (XXX)XXX-XXXX and spoke with (Representative’s Name) (Call Ref #_______). (State what the representative said during the call). (State your plan of action).