Hcr230 General Appeals Process

The general appeals process gives the right for a provider or patient to dispute insurance charges that were previously denied, reduced, or downcoded. The appeal process may only occur after the determination of a claim and the appeal must be filed in the appropriate time frame. However, there are times when a claim is denied, reduced, or downcoded from simple error.
Discussion of different three examples first begins with registration errors. Many times when a patient registers at the same facility, they also have similar names to previous or current patients on a patient list. Unless all staff members are well trained to follow standard procedure to distinguish patient identification, these type of errors will be a constant. Confirming a patient’s date of birth, social security number, and full name is just one step to preventing this error. Secondly, having the patient to verbally confirm their personal identifiers can also prevent this error.
A second example of a claim error revolves around improper preauthorization and/or referrals. Most health plans do not cover services outside of the patient’s network of providers unless they are referred or have preauthorization. Reviewing a patient’s health plan should a outside care be needed and confirming this through the health plan itself can alleviate this error. Patients must also know the specifics of the health plan. Overall, the primary care physician and the patient must have the most up-to-date health information available to prevent such a costly error from occurring.
Lastly, improper eligibility can prove to be a significant error in claims processing. Not every patient’s health plan stays the same, changes can occur with employment, retirement, and financial status which will affect eligibility status for health care. Having a staff member to confirm eligibility prior to services being rendered is a helpful way to prevent claim