The purpose of a General Appeals Process is used to challenge payer’s decision to reduce, deny or to downcode any claim. The provider however, can ask for a review of the payer’s decision. The patient also has a right to ask for a request of the appeal. The claimant or appellant is the one that is filing the appeal. That could be an individual who is the provider or the patient. The basic steps are simple of the appeal. This is where the payer has a consistent procedure to handle the appeal. This has to do with what kind of appeal it is. The practice staff does a review on the procedure before other actions are taken.
The staff then takes the necessary steps to move forward. The appeals must be filed by a certain time after the determination. The payers must go through three steps. These steps are a complaint, an appeal and the grievance. There is not a bunch of time to spend on this procedure. After this is done and the payer is still denying the claim, the claimant can take another step. This can be reviewed through the state insurance commissions since most payers are licensed through them. The state insurance commissions must have all copies of the file and to see why the claim was denied. The reason that the claim was denied to could be simple reasons.
The reasons are mostly human error. The most common claim denials are due to not using the patient’s health care identification number and the correct name on the card. The other reasoning could be not putting down where the services were done. The last but not least could be invalid diagnosis codes. This could all be why the claim is denied.
References Nyman, Ronald E., ESQ, (June 2007), MediStar Meducation , Volume 1, Number 4, www.credentialsxpress.com/newsletters/newsletter1-4 full.htm, Retrieved September 10,2010, Google.