Claim Not on File
in Medical Billing: Understanding and Solutions
Medical billing is a
critical aspect of healthcare administration, ensuring that healthcare
providers receive payment for their services. However, one common issue that
can arise is the "claim not on file" error. This issue can be
frustrating for both healthcare providers and patients, leading to delays in
payment and potentially impacting the financial stability of medical practices.
This article will delve into what "claim not on file" means, why it
occurs, and how to effectively resolve this issue.
Understanding
"Claim Not on File"
In medical billing, a
"claim not on file" error indicates that the insurance company has no
record of receiving a particular claim. This can occur for various reasons,
including technical issues, administrative errors, or communication breakdowns
between the healthcare provider and the insurance company.
Common Reasons for
"Claim Not on File"
- Transmission Errors: Claims can sometimes fail to transmit
correctly from the provider's billing system to the insurance company due
to electronic transmission errors.
- Incorrect Information: Inaccuracies in patient information,
policy numbers, group number or other critical details can prevent a claim
from being properly recorded.
- Administrative Delays: Delays in processing within either the
healthcare provider's office or the insurance company can result in claims
not being filed on time.
- Wrong payer ID: If payer ID for the specific insurance
is not correct or wrongly entered int the billing software then claim will
be misrouted and will not be delivered to the actual insurance company.
- Inactive Insurance: If the member/patient has inactive
insurance then it may be rejected by the insurance side and will enter
into the adjudication system of the insurance and when you will call for
follow up, it would be not on file.
Solutions to
Address "Claim is Not on File"
- Verification of Submission: Always verify that the claim was
successfully submitted to the insurance company. Most billing software and
clearinghouses provide a confirmation or reference number for submitted
claims. Keep these confirmations for future reference.
- Confirm the payer ID: First of all confirm the correct payer
ID from the insurance. You may call to the insurance to confirm their payer
ID for professional and as well as for institutional claim. You can also
verify the correct payer ID from the clearing house website. Like if you
are using Change Health Care clearing house then you can visit their
website to find exact payer for your concerned state.
- Confirm CPID: Clearing house connects itself to the actual
insurance and billing software via CPID (Clearing House Payer ID). Check
CPID in the EDI setting and make sure it is correct for the concerned payer
otherwise your claims are not going to reach the insurance
- Eligibility Verification: First of all try to verify the eligibility of the member. If member is inactive then claim may be rejected before entering into the adjudication system. Check if other insurance is being entered into the system or check the documents of the patient on EHR or try to find the major insurance of the patient that can be verified/searched by the name and date of birth like Medicaid or by SSN like Medicare. If you are still unable to find the active insurance then initiate the request to call to the patient in this regard.
On Call Scenario
Claim is not on file
↓
May I have insurance effective and end
date?
↓
Check DOS lies between effective and termed date
↙
↘
Yes
No
↓
↓
May
I have the TFL? ← ←
Is there updated or any other
policy
↓
↖
active for the patient on DOS?
Check DOS lies
within TFL ↖
↙
↘
↙
↘
↖
Yes
No
Yes
No
↖
↓
↓
↓
↓
← May I
have May I get
May I have claim
Can we fax or
Policy ID, Policy call
ref#?
mailing address,
mail the claim
effective and
Payer ID and Fax#? along
with POTF?
termed Date?
↓
↖ ↙ ↘
May I get call ref#? ↖ ← No
Yes
↓
May I have Fax#
or Mailing address
to send claim along
with POTF?
↓
May I get call ref#?