Week 6 Checkpoint Purpose of the General Appeals Process

Payer’s process thousands of claims every day. Trying to manually adjudicate every single transaction would be unrealistic, time-consuming, and costly. Therefore, payers’ have an adjudication process that consists of initial processing, automated review, manual review, determination, and payment. During the initial processing phase, documentation received through the mail or electronically is checked to make sure all documentation, when paper is submitted are date-stamped, attached, and claim data elements are checked and either scanned or entered into the payer’s system. Then the claim goes to the automated review where the claim is sent through payer’s computer system of payment policy edits. If all checks out, then the manual review is by passed. The next step is the determination in which the decision to deny, pay, or pay at a reduced amount for each line on the claim. Lastly, a EOB/RA or an ERA is generated. The purpose of the general appeals process is for a claimant (provider) and an appellant (patient) to challenge, and hopefully, reverse a payer’s original claim determination of which payment was denied, down-coded, or reduced. Although, different payers’ have different set procedures for appeals depending on their nature, there are three basic steps in the general appeals process such as a complaint, an appeal, and a grievance. These steps have specific filing deadlines after the date of the claim determination and set minimum amounts to be considered. Further, if the appeals process has been followed through and the ending results are not satisfactory, then the claimant can file an appeal with the state insurance commission. So it is a good idea to keep a log of different types of denials and the payer’s reason codes to figure out ways to add or improve current procedures that would reduce the amount of time and money for problematic claims. For instance, avoiding errors such as registration mistakes, such as recording the patient’s name incorrectly...