What information should you review before calling an insurance payer regarding an unpaid claim?

Before contacting an insurance payer about an unpaid claim, the AR representative should first complete an internal review of the account.

The first step is to confirm that the claim was submitted successfully. This includes reviewing the claim submission date, clearinghouse acceptance, payer acknowledgment, and any rejection messages. If the claim was never accepted, calling the payer may not be useful because the payer may have no record of it.

Next, verify the patient and insurance information. Confirm that the patient had active coverage on the date of service and that the correct payer, member ID, group information, and coordination of benefits were used.

The representative should also review the claim details, including:

• Date of service
• Billed amount
• CPT or HCPCS codes
• Diagnosis codes
• Modifiers when applicable
• Rendering and billing provider information
• Place of service
• Claim number, if available

It is also important to check the current claim status through the payer portal or electronic claim status tool when available. The claim may already show as processing, denied, suspended, paid, or pending additional information.

Previous AR notes should be reviewed carefully. These notes may contain prior payer responses, reference numbers, requested documents, appeal status, or a scheduled follow-up date. Reviewing them prevents duplicate work and helps maintain continuity.

If the claim was denied or partially processed, the representative should review the ERA, EOB, denial code, and payer message before making the call. Understanding the existing payer response makes it easier to ask specific questions rather than simply asking, “Why was this claim not paid?”

Any relevant supporting documentation should also be available before the call, such as:

• Proof of timely filing
• Authorization information
• Medical records
• Referral details
• Corrected claim history
• Appeal or reconsideration submission confirmation

The representative should also understand the purpose of the call. For example, the goal may be to verify claim receipt, obtain processing status, clarify a denial, request reprocessing, confirm receipt of documentation, or determine the next appeal step.

A prepared payer call is more efficient and results in better documentation and faster claim resolution.

An AR representative sees a claim that has been unpaid for 70 days.

Before calling the payer, the representative confirms that the clearinghouse accepted the claim, verifies that the patient was eligible on the date of service, and reviews the payer portal.

The portal shows the claim is pending additional medical records. The previous notes show that no records have yet been submitted.

Instead of calling the payer just to ask for status, the representative first gathers the required records and then contacts the payer only if clarification is needed regarding the submission process.

This saves time and avoids unnecessary follow-up.