Denied Claim? Make An Appeal The Right Way

Wed, Nov 16, 2011 --

Skill Sharpener

For billers and coders, “DENIED” is the most dreaded word, but you don’t have to take it lying down.

As painful as it may sound, but an appeal is worth every effort. You have the right to appeal when Medicare or your insurance company denies or pays less than the full amount of your claim. But before you appeal a denied claim, take a good look at the denial document and familiarize yourself with the facts. This document lays out the reasons for the denial or partial payment of your claim and you will need to contest this explanation to win. You may want to seek your doctor’s help to frame the appeal and elaborate reasons why a medical care given in the specific manner was necessary.

Remember: Most insurance companies have a time frame on when claims need to be appealed, so read your policy documents too carefully. Contact your insurance provider immediately for any confusion. If you get a Medicare-covered service, you must appeal within 120 days of receiving the denial or Medicare Summary Notice. Fill the “Medicare redetermination request form”, which can be downloaded from http://www.cms.gov/cmsforms/downloads/CMS20027.pdf and send it your Medicare contractor. You can expect a response within 60 days.

Documentation: Be sure to include copies of the doctor’s letter, medical bills, and all documents along with your “redetermination form” and also check on the progress of your case periodically. If you need help filing a claim, you can contact your State Health Insurance Assistance Program (SHIP). If you find your appeal being denied too, consider approaching a state agency. Note: Check for any errors in the claim you submitted. Rectify any fault that you notice and consider resubmitting it with the correct information.

About 

Barnali is a medical coding and billing writer at TCI who has worked in the healthcare industry since 2009. She holds a master’s degree in English literature and a diploma in advertising and marketing. She enjoys writing about ICD-10 and Medicare compliance.

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