Overview
Nothing is more frustrating than submitting a claim for payment and having the claim denied. Whether the reason is as simple as an incorrect beneficiary name, inappropriate bundling, or a question of medical necessity, this initial determination of a claim from the carrier is the bane of existence for many providers. It takes time and effort for the billing staff to determine if the determination was appropriate. In order to get these denied claims paid, there are certain appeals processes for both Medicare and commercial insurers which can be different and must be followed.
Steps:
1. Find out if you have a provider representative—who they are and their correct contact information.
2. Work with the payer and/or provider representative to find out what their policy is around how you should communicate with them about mass appeals. Also, you will want to identify the answers to the following questions and record them in a process document for that payer:
Do they have a special format that needs to be used?
Do they have a payer reconsideration portal where you should upload the information?
Should you send it via secure email to the provider representative or to a specific email address?
Do they require you to call customer service and have obtained a call reference number before you send it to the provider representative?
Third: Make sure you understand the follow-up process and what the reconsideration/appeal timeframe will be for the payer. Appeal time frames can often be listed and/or referenced in the contract.
If you have any additional questions about Appeals with Rivet, feel free to chat in or email at support@rivethealth.com.
Suggested Next Article - Sending Appeal Emails and using an Appeal Template