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Billing Managers

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Please update the primary payer on claim ABC123 to Cigna.

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Billing Managers

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How do I update the primary payer on claim ABC123 to Cigna?

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Billing Managers

Front Desk

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Create a message to the support team about Claim [ID Number]

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📧 Bold Subject Line (for support inbox)

Subject: Claim Inquiry — Claim ID ABC123 — Sally Smith (MRN SS-004219) — Request for status/reconsideration

🧾 Issue Summary (one-line)

Patient Sally Smith — Claim ABC123 submitted to Health Plan of Nevada (HPN Choice PPO) for Right Total Hip Arthroplasty (CPT 27130); requesting status update and/or reconsideration due to documented medical necessity and completed conservative care.

🔎 Detailed Request

Hello Support Team,

Please review Claim ID ABC123 for patient Sally Smith (MRN SS-004219, DOB 06/15/1981). We are requesting a status update and reconsideration/expedited review because the attached clinical documentation demonstrates medical necessity for Right Total Hip Arthroplasty (CPT 27130) and that the patient has appropriately failed conservative care.

Key facts:

Member / Subscriber ID: HPN-CM-448921 • Plan: HPN Choice PPO • Group #: 77431.
Procedure requested / billed: Right Total Hip Arthroplasty — CPT 27130.
Primary diagnosis: M16.11 (primary osteoarthritis, right hip) — radiographic KL grade 4, MRI confirming full-thickness cartilage loss and marrow edema.
Conservative therapy documented: 16 supervised PT visits (01/08/2025–02/28/2025), NSAID trial (meloxicam), activity modification ≥12 months cumulative, cane use, ultrasound-guided intra-articular steroid injection (02/10/2025) with <2 weeks relief. Functional impairment persists (HOOS Jr 30/100, pain 8–9/10, ambulates ≤1 block with cane).
Pre-op optimization / clearance: Normal pre-op labs, EKG, CXR; BMI 29.1; nonsmoker; anesthesia pre-op evaluation completed.
Operating surgeon: Priya Desai, MD, FAAOS — NPI 1447556677.
Facility: Saint Mary’s Regional Medical Center — NPI 1326196625.
Requested disposition: Outpatient or 23-hour observation per plan.

Please confirm:

Current processing status of Claim ID ABC123.
If additional documentation is needed to adjudicate or reverse any denial (please specify exactly which documents and preferred submission method).
If prior authorization is required for this claim or if it was denied/paidsplit; provide denial reason(s) or remittance remarks.

📎 Attachments included with this request (please confirm receipt)

Operative/procedure request and consent (THA) dated 2025-09-12.
Clinical summary / medical necessity justification (radiology reports: X-ray 03/01/2025 CPT 73502; MRI 03/15/2025 CPT 73721).
PT records (16 sessions, 01/08/2025–02/28/2025).
Injection note (US-guided IA steroid, CPT 20611; J3301 x8) 02/10/2025.
Pre-op labs & clearances dated 2025-09-12 (CBC, CMP, coag panels, A1c, EKG, CXR).
Surgeon contact information for peer-to-peer: Priya Desai, MD — pdesai@sportho.example.com — (775) 555-0142.

⚠️ Operational / billing notes

Billing diagnosis: M16.11 (primary) with secondary codes M25.551, G89.29, E78.5 as clinically appropriate.
Procedure CPT 27130 should be linked to the services above; please advise if a modifier is required for outpatient/observation setting.
If the claim was denied for lack of prior auth, please identify the specific authorization code required and whether retrospective PA is allowable.

📞 Contact for follow-up

For clinical or peer-to-peer review:

Dr. Priya Desai, MD — pdesai@sportho.example.com • (775) 555-0142.

For billing/claims follow-up:

Enter Health Billing — [Your Name] — enterbilling@example.com • (775) 555-0100 (ext. 2).

Please confirm receipt of this message and list any missing items so we can supply them immediately. We appreciate your prompt attention given the patient’s severe functional impairment and work/sleep limitations.

Thank you,

[Your Name]

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Billing Managers

Front Desk

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Create a message to the support team about Claim [ID Number].

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Billing Managers

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What contract/chargemaster governs today’s DOS?

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Billing Managers

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What payments has John Doe made this year?

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Billing Managers

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What payments has John Doe made this year?

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Billing Managers

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What’s the status of Claim [ID Number]?

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Providers

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Can you fill out this prior authorization form for this CT scan?

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Billing Managers

Front Desk

Providers

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Does this plan require prior authorization for PT services?

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The plan requires a PA when the requested PT exceeds the allowed number of visits per benefit period, when the case is post‑operative with progressive intensity (risk of high utilization), or when interventions include repeated manual therapy and therapeutic exercise that the insurer flags for review. The insurer’s policy also mandates documentation of objective deficits, prior conservative treatment, and a time‑limited, measurable POC showing expected functional gains — absence of these triggers a PA requirement.

📋 One‑line PA justification (to paste into a portal)

“Requesting prior authorization for outpatient PT due to post‑operative left shoulder repair with objectively limited ROM, pain limiting ADLs, and proposed skilled PT (97110, 97140) exceeding plan visit limits; supporting docs attached (PT eval, POC, surgeon note, prior conservative care).”

🧾 Key documentation to attach (minimal submission package)

PT evaluation with objective ROM/strength and validated functional scores.
Plan of Care (frequency, duration, measurable goals, skilled interventions).
Surgeon/consult note confirming procedure and post‑op timeline.
Progress/physician notes or prior conservative care showing inadequate home program response.
Relevant imaging (if it supports severity or surgical intervention).

✅ PA request details

ICD‑10: M75.121 (left rotator cuff).
CPTs requested: 97161 (eval), 97110 (therapeutic exercise), 97140 (manual therapy).
Visits requested: 12 visits over 6–8 weeks.
Objective goal: Increase active forward flexion from 60° to 140°; decrease pain from 6/10 to ≤2/10; return to independent overhead ADLs.

📞 Two‑line call script to confirm with payer

“Hello — verifying benefits for this UnitedHealthcare Choice Plus member: does this plan require prior authorization for outpatient PT when requesting 12 visits for post‑operative shoulder rehab (CPTs 97110, 97140)? What documentation is required and what’s the fax/portal for submission?”

Would you like me to generate a one‑page PA narrative using the example details above that your team can paste into the payer portal?

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Front Desk

Billing Managers

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How much does [patient name] owe right now?

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Front Desk

Billing Managers

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Show me all claims for John Doe between 2024-07-01 and 2024-07-31

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Front Desk

Billing Managers

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How much does [Patient Name] owe right now?

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Connect to the ENTER RCM Platform For Instant Data Access

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Part 1: ENTER Platform

Download CTRL ENTER
Open your ENTER RCM platform and navigate to Settings → Development → API Keys
Locate your CTRL ENTER API and Secret Keys
Copy your API key and Secret Key

Screenshot of CTRL ENTER with the places to paste in the API key and Secret key highlighted

Part 2: CTRL ENTER

Open CTRL ENTER and click the 3 dots on the top right corner of the CTRL ENTER window
Navigate to Platform
Under Set Up Integration, paste your keys into their respective key fields
Click Save

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Connect to the ENTER RCM Platform For Instant Data Access

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