Claim Not On File

One of the most common denial you will get while working in medical industry is “claim not of file”. This basically means claim is not received by the payer/Insurance.

Once you file the claim, depending on the Timely Filing of each claim and the mode of submission (Paper or Electronic), if there is no response from insurance company and it has passed our clearing house, we will try to check with insurance company either via phone or their web portal as to why the Claim is not on file?

Claim Arrival Timeframe With Insurance: What To Do After Claim submission?

Electronic claims can reach the insurance company within 3-7 days. If you want to check the status, you can do that after 7 days. For paper claims, they may take 15-30 days to arrive at insurance or it can be loner depending on the state.

It is good practice to check with insurance after 20-30 days, allowing the insurance ample timeframe to process it. However, in case of Electronic form submission, it is equally important to keep checking your clearing house, your PMS (practice management softwares, EDI) for any rejections every day. Claims can stuck and can remain there in your clearing house scrubbers until further action is taken. Otherwise, if claims remain stuck for more then 30 days, The A/R Department should pick up on the claim.

If claim has moved successfully from your system after submission and once the timeframe of 30 days have passed and there is no response from the insurance company on Paper or E claims, then we get in touch with insurance company to check the status of the claim.

Claim Not On File – Paper Claim

Whatever practice management software you work, you will find out whether the claim was sent via paper or was it sent electronically. If paper claim has not reached the insurance company then you will do the following:

Patient Eligibility

First you will confirm the patient eligibility meaning you will check with the insurance company you have sent claim to, does the patient has that insurance cover or does he/she belong to any other insurance company or was insurance active on that particular day of service?

Correct Insurance

If there is any Eligibility issues, then you will have to find the insurance company whom the patient is registered with. You can also talk to the patient to find out. However, if the eligibility is correct, then you will check whether your provider is participating with that insurance company or not or has he done credentialing with that insurance company?

Insurance Address

Third step is if there is no issue with provider participation with that insurance then you will confirm the address on which this claim was sent. Is that address accurate or not or if we have sent the claim on wrong billing address by mistake? Or it could be that address of the insurance company has changed!  Also, on the patient insurance card back side there is an address for that insurance and if the claim is to move electronically, then there is Payer ID, with payer ID we can send the claim electronically.

If the address is correct along with other details, Then the best approach should be to send the claim electronically. To do that, first confirm the payer ID and then send it electronically.

Fax – The Fastest Way To Submit Healthcare Claims

The fastest way to make your claim reach the insurance company is by Fax. You can send the claim directly to the insurance company fax number along required documentation for claim processing and then we can receive the claim acknowledgement receipt via fax.

Claim Not On File – Electronic Claim

Check EDI in PMS (Practice Management Software)

Once you submit the claim electronically and you came to know that Claim is not on File. First thing to check if there is any EDI rejection in the system! EDI stands for electronic data interchange.

Whatever claim we make in the system and send it electronically, the insurance company also receive that claim electronically through clearing house (clearing house works has intermediary/bridge between insurance and provider who checks all the Edits whether there is any deficiency in the claim and then submit electronically to the insurance company on Electronic payer ID).

Correct Payer ID or any mission/incorrect information

Every insurance has unique payer ID and electronically we are meant to send that on that payer ID. Once clearing house send the claim to the insurance with that payer ID, that claim will automatically get loaded in insurance company software.

If claim is not on file, we need to check if there is mistake, any lack of information or have we put in any invalid character in the claim or put in any invalid diagnosis code or there is any mistake in patient information then in such cases clearing house normally gives one rejection and we have to check that.

Steps To Check Why Claim Not On File?

So first we check our EDI rejection which means has our claim passed electronically or not? Usually most of the senior people does this job because in this we do not wait for 20-30 days, we check them in 24 hours if there is any EDI rejection or not. If we could not check within 24 hours and after 30 days it goes into aging, then you pick up there that this is claim is not on file, then first thing you need to do is to check the EDI whether there is any rejection in EDI or not. If claim is not on file after submission, please do the following:

- Confirm patient eligibility same as we do in the paper claim scenario.

- Confirm provider participation status same as we do in the paper claim scenario.

- Confirm mailing address: here since we are doing electronically, then we need payer ID, but if after repeated attempt of electronic submission and insurance keep saying not on file, then we send the claim via paper so for that we confirm the mailing address.

- Confirm fax number same as we do in the paper claim scenario.

If you are receiving a lot of denials and unable to work out "Claims not on file". Please contact us info@mtservices.pro