Do you get authorization prior to treating a patient, yet still receive claim denials? This is a common issue that providers face on a regular basis and unfortunately, there is not a simple solution. One option is to have the claim reprocessed. Most likely, you will need to write an appeal.
Even if your claim denial is overturned, the appeal process will cost you time and money: Consider the time it takes to write an appeal letter, gather the clinical documents to support your case, and the phone calls to ensure the appeal is in review. The average appeal letter takes 90 days to be reviewed reeking havoc on your accounts receivable.
Level 1 Appeal:
To overturn a claim denial, you must write a clear and concise letter explaining why the service you performed was medically necessary.
In the top left corner of the letter, you will list the name of the patient, the policy ID number, the claim number assigned by the insurance company and the dates of service in question. Next, you will state the reason the claim was denied using the denial reason code on the Explanation of Benefits. You will also need to provide a brief history of the patient's illness and why the service or treatment was medically necessary. Use factual, evidence-based information to support your claim.
If there is a prior authorization number on file or any conversation between the your office and the insurance company, include the reference number and relevant notes from the call. Attach all of the relevant clinical notes you have on the patient and any documents you received from the insurer regarding the claim.
Once the insurance company makes a decision, you will receive a written notice that states the final determination and hopefully, a payment.
Level 2 Appeal
If your initial insurance appeal is denied, you will need to request an external review of the claim. This is also known as a second-level appeal. Below are the most common examples of claim denials that require review by an outside board.
A rejected provider dispute claim (appeal)
A determination that lists the service as experimental
A canceled policy or claim denial for treatment that you believe should be covered based on information provided by the insurance company during enrollment
Guidelines for submitting an external review can vary by state but typically follow the Department of Health and Human Services guidelines. You can find instructions on how to submit an external review of the denial letter you receive from the patient's insurance provider. You can also request a form directly from the Department of Health and Human Services website.
To find out if your accounts receivable is in good health, contact the Datapro billing team for a complimentary unpaid claims review.
For more information on this topic and much more, view our Behavioral Health Guide to Quick and Accurate Claims Processing. You can also download a PDF document by clicking on the image below.