Purpose of General Appeals Process

Purpose of the General Appeals Process

First, let’s define the word appeal, appeal is a process that can be used to challenge a payer’s decision to deny, reduce, or otherwise downcode a claim. When it comes to appeals there are basic steps for handling them. Appeals must be filed within a specified period of time after the claim determination. There are structures of appeals such as a complaint, an appeal, and a grievance. The three levels have to be moved through in that order. There are also set minimum amount that a claim have to be in order to file an appeal to ensure that too much time is not wasted on a small dispute.

If a claimant has been rejected on all levels of the appeal process then the claimant is able to go through with an appeal through the insurance commission office. Copies of the complete case file and all documents that relate to the initial claim determination and appeals process must be sent in, along with a letter of explanation.

The three examples that I located was that

1) A claim was denied because the record showed that the beneficiary was not entitled to Medicare coverage for the type of services billed.

2) An outpatient claim was billed for the same date of service for the same provider number.

3) The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services on the claim. Therefore, no Medicare payment could be made.

All of my examples was basically billing errors and failure to ensure that the patient was covered and also that the procedures that they were getting was also covered.