Denials with solutions in Medical Billing

Denials in Medical BillingDenials Solutions - AR Denial Management
Coding denials:Click here for complete list of Medical coding denials with solutions.
Authorization denials:For this denials we need to look into following 3 segments: Procedure code, Provider and Place of service to resolve the denials:

Procedure Code:
1) First check EOB/ERA to see which procedure code require authorization or reach out claims department and find out which procedure code require authorization.
2) Check in software application/claims department to see authorization available. If available and valid for the service, then update and send the claim back for reprocessing.
3) If authorization not available, then check with representative whether we can obtain retro authorization for that particular procedure code.
4) If we cannot obtain retro auth, then you have right to appeal the claim with necessary documents.
5) If appeal upheld, then escalate to the client for further action(Write off).


Provider:
1) First check provider is in-network or out-of-network provider with the insurance.
2) If its in-network provider, find out whether authorization required for the particular service. If authorization not required for in-network, then send the claim back for reprocessing.
3) If suppose authorization required, then follow the procedure code segment steps(2, 3, 4 and 5)

Place of Service:
1) First see the place of service code billed. Because if its an emergency, then authorization not required.
2) If the place of service is 23(Emergency), call the claims deparment and send the claims back for reprocessing.
3) If the place of service is some other and require authorization, then follow the procedure code segment steps(2, 3, 4 and 5)
Claims Lack Information denials:When you get the denial Claims lack information or need additional information then follow the below steps to resolve the issue:

1) Check the EOB and find out what type of information required and from whom (Patient or provider) by seeing RARC (Remittance advice remark code) in order to reimburse the claim or reach our claims department if the information is not clear.

If the Information required from Patient :
a) Check when insurance have sent the letter to patient requesting the missing or lacking information.
b) If it is more than 30 days check to see if patient has updated the requested information with insurance.
c) If patient has already updated, then send the claim back for reprocessing.
d) If not update, then request insurance to send one more letter to patient to update the missing information.

If the information required from provider:
a) If you found the exact information that what insurance need from provider, then resubmit the claim with missing or lacking information for reimbursement.

Note: RARC place a major role in finding out the exact information required from the insurance company
Non Covered Services denials:1) First check EOB and find out whether the non covered services is as per the patient plan or as per the provider contract related.

Patient responsibility related:
a) Check in application whether same services previously paid from insurance or not.
b) if paid, then send the claim back for reprocessing.
c) If not paid, then take the action as per the provider specification (Bill patient or write off as per the client specification).

Provider Contract related:
a) Check in application whether previously paid the same services or not.
b) If paid, then send the claim back for reprocessing.
c) If not paid, then check the insurance website to see the policy and find out the services not covered as per the contract.
d) As per the policy if the services not covered as per the provider contract, then write off the charges.

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