Members can also file an appeal or grievance with their health insurance company if they feel payment was warranted.
The way a claim is coded and billed determines how an insurance carrier processes the claim for payment. Providers file appeals and grievances for claims that are either denied, processed incorrectly or were never processed because it was filed past the timely filing deadline. Members can also file an appeal or grievance with their health insurance company if they feel payment was warranted. Appeal requests must be made in writing and all supporting documentation attached for medical review.
Instructions
1. Call the insurance company. Find out exactly why the line items in question did not process to pay.
2. Ask where to send the appeal and attention the envelope to the correct department.
3. Print out chart notes from the encounter and review the documentation to be sure it supports what you are appealing.
4. Attach outside resources that validate your request for an appeal. Consider using information from the American Medical Association or a publication from the Centers for Medicare and Medicaid Service.
5. Write an appeal letter identifying the patient, date of service and claim number. Clearly state why you are appealing the insurance company's decision, reference the supporting documentation and request correspondence as to the outcome of your request.
6. Attach a copy of the payer's Explanation of Payment (EOP) or Explanation of Benefits (EOP) and mail out the appeal.
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