CHECKPOINT: PURPOSE of GENERAL APPEALS PROCESS
The appeal process is used to challenge a medical claim that has been reduced, denied, or is a down code claim. The appeals process begins when the provider request a review of the payers decision to deny a claim. The person that files the claim is known as a claimant or appellant depending on if it is a provider or patient who files the claim. Procedures for handling medical claim appeals may vary between the payer and the reason for the appeal. There is a required time frame for the appeals process after the claim determination. Most payers have a structure of appeals consisting of the complaint, appeal, and grievance. There are three levels involved during the medical claim appeals process. Most payers require a minimum amount to be set so take is not used for small dispute amounts. The appeal process can result in a reduced or denied payment of a medical claim.
There a several reasons a medical claim may be denied by the payer. If the patient has other primary medical insurance or, the patient as a workers’ compensation claim. or, an automobile claim there is specific information that is required. The scheduler has to ensure they have the patients’ correct and updated information. Workers’ Compensation and auto accident claims require the patients claim number, adjusters’ name, and all services require preauthorization. An error in relation to this example is considered a billing error. Another example of a billing error is the absence of a referral on file because most HMO’s require a referral. An example of a registration error would be that the patients’ insurance information changed and no longer covers a service provided (2008).
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