Review Claims Contract: If you are part of a managed care product (PPO, POS, or HMO), then review the claims contract to ensure that you are following their procedures.
Prepare an Appeal Letter: Be sure to include the patientâ€™s name, health insurer ID, subscriberâ€™s name, and insurer numbers along with the date of service and the reason for challenging the denial.
Use Thorough Information: Be clear and thorough by documenting the reasons for your argument. This means using information from you, the patient, and objective data such as the medical record.
Review Letter: Be sure to have the treating physician review the denial claim letter so that it is accurate and they can sign it. Also include all relevant documents before sending it.
Use a Contact: Youâ€™ll want to know that your letter has been received, so be sure to include a contact name at the insurer. All too often, denial claims can get lost if you donâ€™t have a person there to contact.
Have a Physician Review the Claim Appeal: This means you will need to request that the insurer use a physician in the same specialty to review the letter. Be sure to write down the reviewing physicianâ€™s name for follow-up purposes as this will be crucial if the letter is rejected and you want to appeal again. You will also way to request a phone review, not a written one as that can take much longer.
Fax the Documents: If the health insurer accepts documents that are faxed, you really should consider that option. This means faxing the claim appeal letter and any supporting documentation that you have available. Faxing is considerably faster than mailing the information which may speed up the review process. The good news about faxing is that you can receive confirmation that the fax has gone through.
Use Certified Mail: If the health insurer does not accept faxed documents and only takes them by mail, then send it through certified mail so that you can get a receipt that confirms they have the received the information. Even if the health insurer does not acknowledge it with you, you will have the return receipt from the post office to show that it was delivered to their address that includes the time and date.
Follow Up Regularly: Youâ€™ll want to follow up with the health insurer rep on the status of your claim appeal on a regular basis. You should be kind and considerate, but staying in touch on a regular basis is vital to ensure that you at least find out how it is proceeding.
Always Be Proactive: Keep a file that has common claims denials based on administrative and medical necessity so you have a template for your next letter. This is an important part of your denial management approach.
Article Source: https://www.bharatbhasha.com
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Article Added on Tuesday, August 2, 2016
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