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Archive for April, 2012

Medical claims can be denied for many reasons. In most cases the reason for the denial is listed by codes right next to the service line. At the bottom of each Explanation of Benefits (EOB) there should be a code explanation. If the explanation is not listed or you don’t understand the first thing to do is find out or clarify what is being denied and why.
By calling your insurance customer service you can ask questions about a denial and full explanation should be given. During this phone call you may find out that the insurance made a mistake and your phone call of inquiry can prompt the customer service person to send back the claim for reprocessing. In this case, don’t feel completely relieved just yet. There are many things can go wrong and your denial could stand the same after thins phone call. So, the best thing to do in this situation is to mark your calendar in 30 days, note the date of your phone call, the name of the person you spoke with and if any reference number given. This way in 30 days you can follow up with a second call if the claim has not been paid.
Once the reason for denial is fully understand you can file an appeal. Always be sure to have the correct appeals address for your insurance. Letters and faxes often go to a specific department, so sending a letter to the wrong address can further delay the answer. Some of these companies are big that your letter can be easily misplaced and land in the “black hole”. I have heard insurance company representatives using this term.
The next important part is listing your information before your letter begins. This should include your name, your insurance ID number, the date services were provided, your address and the claim number listed on the denial.
The first sentence should state that this is an appeal and you are disputing the denial.
The body of your letter needs to explain what taken place and why this claim should be paid. Try to be clear and free of emotion. Accusing a person reading this letter will not help your appeal.
The closing sentence is the repeat of your demand for payment.
If you have supporting documentation of any kind you need include that with the letter.
Time: most claims have 180 days appeal limit, from the time a claim was processed. State laws and policies may vary slightly.

Types of denials:
• Coverage based
• Technical
• Medical

Coverage based: these are denial when the insurance company states that your policy does not cover this service.
Example: a client had an oral device made by a dentist to treat his sleep apnea. The claim was denied based on the dental component. I successfully argued that his oral appliance was to treat a medical condition.

Technical: these are claims denials mostly for timely filing or coding problems.
Most claims have to be filed within a 180 days from the time services were provided. Missing this deadline will produce a timely filing denial.
Example: the patient was hospitalized for an extended time period, therefore could not file a timely appeal.
Coding problems: each medical claim have to contain a several numbered codes, such as provider tax ID, place of service, CPT or HCPCS, diagnosis, NPI or license numbers. Missing or using a wrong one will produce a denial. In this case there is no need for an appeal. Simply you need to decipher which code needs a correction and simply can resubmit a claim with correct codes.
I am fully expecting these denials to multiply starting on October 2013. That is when the ICD-10 coding change will be implemented and codes will multiply by nearly 55,000.

Medical: these are services denying by the insurance saying that the service was not medically necessary for your specific condition. The appeal should explain why it was necessary and be paid.
In case the first level of appeal is denied I always file a second level of appeal. The review of this appeal takes place with a different department and there is a chance to overturn the first level of denial.

If a second level of appeal is denied there is always an option to file the next level to the Commissioner of Insurance or the Benefit Administrator. The deciding factor is based on the type of policy the person have. Fully funded insurance policies are appealed at the Commissioner of Insurance level, and self-funded insurance policies are appealed at the Benefit Administrator.