Denial claim handling problems and how to solve it

General Problems

• Not appealing denied claims
• Appealing denied claims without making any changes in the claim
• Poor documentation
• Using improper terminology
• Not getting all charges billed

Not Appealing Denied Claims

• All denied claims should be reviewed by the physician and the billing specialist for correctable errors
• Correct the errors and resubmit the claim as a corrected claim

Appealing Denied Claims

Without Making Any Changes

• The definition of insanity is doing the same thing over and over with out changes and expecting different results
• Correct the errors and resubmit as a corrected claim

Poor Documentation

• The documentation should support the level of service coded
• Document what you do and code to the documentation
• Separate the E/M service from the radiology and procedures in the note

Not Getting All Charges Billed

• Audit the transfer of information from “routing slip” to billing program
• Make sure all charges get appropriately billed

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Denial appeal time limit - Prestige health insurance

3. Request for Standard Determination
In the event a provider wishes to file an appeal on behalf of a member, the provider and member must complete an Appointment of Representative statement, which can be found in the Forms section of the Provider Manual, to request a standard determination. Prestige Health Choice will make a determination and provide written notice of the resolution of the Appeal within 45 calendar days from the date of receipt of the standard request.

4. Request for Retrospective Determination

The provider and member must complete an Appointment of Representative statement, which can be found in the Forms section of the Provider Manual, to file a request for a retrospective determination.

Prestige Health Choice will make a determination and provide written notification within 45 calendar days from the date of receipt of the retrospective request.

5. 14-Day Extension

The Expedited, Standard and Retrospective Determination periods may be extended by up to 14 calendar days, if the member requests an extension or if Prestige Health Choice justifies a need for additional information and documents how the extension is in the interest of the member. If an extension had not been requested by the member, Prestige Health Choice will provide the member with written notice of the reason for the delay.

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