Insurance companies will occasionally mail EOBs indicating that a claim was denied, rejected, underpaid, or requires additional action. These claims can easily fall through the cracks if they are not tracked properly. The purpose of this process is to ensure every denied claim is logged, assigned, and followed through until resolution.


📚 Resources Needed


🚀 Tips & Workflow Standards

  • All denial EOBs should be reviewed the same day they are received.
  • Every denied claim must be entered into the EOB Tracking Form.
  • Always upload a copy of the EOB.
  • Never assume someone else is working on a denial.
  • Every denial should have a status and next action.

     

📘 Instructions

1. Review Incoming EOB

When opening mail, review each EOB carefully.

Determine if:

  • Claim paid correctly
  • Claim paid partially
  • Claim denied
  • Claim rejected
  • Additional information requested

If the claim paid correctly, no further action is needed.

If payment was denied, reduced, or additional action is required, continue to the next step.


2. Submit Claim Issue Form

Complete the Claim Issue Form immediately.

Include:

  • Patient name
  • Insurance company
  • Date of service
  • Claim number (if available)
  • Reason for denial
  • Upload EOB
  • Any notes from the EOB

     

3. Review Patient Account

Open the patient account and review:

  • Visit details
  • Claim information
  • Documentation
  • Coding
  • Insurance information

Look for anything that may explain the denial.


4. Investigate the Denial

Common denial reasons include:

  • Missing authorization
  • Coding issue
  • Missing documentation
  • Eligibility issue
  • Duplicate claim
  • Timely filing issue
  • Coordination of benefits issue

Document findings in the tracking system.


5. Take Action

Based on the denial reason:

  • Correct and resubmit claim
  • Upload requested documentation
  • Contact insurance company
  • Verify patient insurance information
  • Escalate to billing team if needed

Document all actions taken.


6. Update Tracking Status

Update the tracking form with:

  • Current status
  • Actions completed
  • Notes
  • Follow-up date

This ensures the claim does not get lost.


7. Follow Up Until Resolution

Continue monitoring the claim until:

  • Payment is received
  • Appeal is completed
  • Balance is transferred appropriately
  • Claim is officially closed

Do not close an item simply because it was submitted.

Verify the issue has actually been resolved.


⚠️ Critical Reminders

  • Every denied EOB must be entered into the tracking system.
  • Upload the EOB whenever possible.
  • Never leave a denial without a follow-up plan.
  • Do not assume insurance companies will automatically reprocess claims.


📞 Support

If you are unsure how to resolve a denial or need assistance interpreting an EOB, notify management immediately.