Claims Report Practice
Week 4 UHB Assignment
Farren Bearden
01/19/2014
Instructor: Breezy Houston
Week 4 Assignment: Claim Determinations Four claim determinations that can be appealed are: Payment is denied, Payment was processed at an incorrect level, Services are denied, and Claim is denied. When payment is denied it’s usually for reasons that are not clear to the hospital or the hospital has more information to prove that the denial is in error. Services are denied based on the payer’s preexisting condition provisions. Claim is denied usually for reasons relating to authorization or precertification requirements (Ferenc, pg. 498). Depending on which determination you are appealing, the first step is Redetermination by Medicare Administrative Contractor (MAC) (Ferenc, pg. 499). Next, you have to go through the Reconsideration by Qualified Independent Contractor (QIC) (Ferenc, pg. 499). Then, you go to the Administrative Law Judge Hearing, on to the Appeals Council Review. And last, to the Judicial Review in U.S. District Court (Ferenc, pg. 498). An uncollectible account is basically an account or charge for service that has no virtual chance of being paid. This can happen for many reasons including: Inability to find the payer, lack of proper documentation, lack of proper authorization, etc. The procedures required for submission of an appeal change depending on the payer and the type of review requested. The basic steps are: Prepare form required, prepare supporting documentation, review medical record to identify information that explains medical necessity, obtain contact information from the insurance company, and submit the appeal information. Prepare the form required by the payer that outlines the reason for the appeal. Prepare all supporting documentation such as remittance advice, copy of the policy, etc. If the claim is denied for medical necessity, review the medical records to identify information that could explain the exact medical necessity. Obtain contact
Farren Bearden
01/19/2014
Instructor: Breezy Houston
Week 4 Assignment: Claim Determinations Four claim determinations that can be appealed are: Payment is denied, Payment was processed at an incorrect level, Services are denied, and Claim is denied. When payment is denied it’s usually for reasons that are not clear to the hospital or the hospital has more information to prove that the denial is in error. Services are denied based on the payer’s preexisting condition provisions. Claim is denied usually for reasons relating to authorization or precertification requirements (Ferenc, pg. 498). Depending on which determination you are appealing, the first step is Redetermination by Medicare Administrative Contractor (MAC) (Ferenc, pg. 499). Next, you have to go through the Reconsideration by Qualified Independent Contractor (QIC) (Ferenc, pg. 499). Then, you go to the Administrative Law Judge Hearing, on to the Appeals Council Review. And last, to the Judicial Review in U.S. District Court (Ferenc, pg. 498). An uncollectible account is basically an account or charge for service that has no virtual chance of being paid. This can happen for many reasons including: Inability to find the payer, lack of proper documentation, lack of proper authorization, etc. The procedures required for submission of an appeal change depending on the payer and the type of review requested. The basic steps are: Prepare form required, prepare supporting documentation, review medical record to identify information that explains medical necessity, obtain contact information from the insurance company, and submit the appeal information. Prepare the form required by the payer that outlines the reason for the appeal. Prepare all supporting documentation such as remittance advice, copy of the policy, etc. If the claim is denied for medical necessity, review the medical records to identify information that could explain the exact medical necessity. Obtain contact