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HOW TO AVOID
CLAIM DENIALS
AND INCREASE
REVENUE FAST
STEPHANIE THOMAS CPC CANPC
OBJECTIVES
TYPESOFDENIALS
IDENTIFYDENIALTRENDS
WORKDENIALSQUICKLY
ANDEFFICIENTLY
DETERMINEWHETHER
APPEALISNECESSARY
FEELCONFIDENTINAPPEALS
PROCESSES
IMPLEMENTSTRATEGIESTO
REDUCEPAYERDENIALS
TYPES OF DENIALS
• Front end edits:
• Also called “Unbilled” “Code correct” “Pending with errors”
• Clearinghouse edits:
• Also called “exclusions” “clearinghouse rejected”
• Denials
• EOB denials, ERA reports
FRONT END
DENIALS
1. Demographic info
2. Internal coverage dates (ex policy
termed 8/31)
3. Authorization info
4. NDC and quantity
5. Referral, referring NPI
6. General coding guidelines
7. ICD10 verification
CLEARINGHOUSE DENIALS
• Coverage/eligibility (more definitive)
• Subscriber info (DOB, address, ID #)
• Provider credentialing
• Referrals
• Authorizations
• ICD 10 errors (unspecified, missing digits etc.)
• MSP (Medicare secondary claims)
EOB DENIALS
Coverage and
COB
Authorization
and referrals
Global period
Medical
Necessity
Non covered
benefits
Medical
Records needed
Credentialing
(non-
participating
provider)
Duplicate
Claim lacks
information
LET'STALKABOUTPATIENT
FINANCIALAGREEMENTS
ANDGOODFAITHESTIMATES!
MEDICARE APPEAL PROCESS
• Reopening's
• Allows for providers to correct
clerical errors/omissions without
having to request a formal appeal
• Can be initiated via the following:
• Telephone
• In writing
• Online portal
• Examples of approved reasons for
reopening
• Billed amount
• Rendering NPI and PTAN
• Diagnosis (some exclusions apply)
• Modifiers (some exclusions apply)
• MSP type
• CLIA numbers
• Place of service
• Unapproved reasons for reopening
• Claim line additions and deletions
• Year of service
• Claims previously reviewed by
redeterminations, Recovery auditor,
recoupment or paid by another
contractor
• Billing provider information
• Unlisted procedure codes
Denial work/Appeal timeframes
• Aetna
• Most states are 180 days from initial claim
determination
• COB issues allow up to 24 months
• Blue Cross
• Appeals for Regence, Empire and Anthem can be
done on Availity®, other plans have specific
forms on their respective websites
• Time limit is 180 days from initial determination
date
• Cigna
• Specific form required
• Include original EOB with request
• Experimental and/or investigational denials
must be appealed by patient/beneficiary
• Workman's Compensation
• Proceed with appeal letter. Include patient claim
# and how treatment is directly related to
compensable injury. Contact adjuster for
additional info on denial.
• United Healthcare
• Submit appeal electronically using the Claims
Reconsideration application on Link (preferred
method) or utilize specific payer form
• Time limit to appeal is 120 days after initial
determination
• Second level appeals must be filed within 60
days
ADDITIONAL TIPS FOR SUCCESS
Follow up 20 days
after corrected
claim or appeal
submission to assure
receipt, then every
30 days until paid
Enlist the patient's
assistance early with
troublesome claims
Keep a log of denials
to track progress
and learn denial
trends
Review coverage
guidelines often for
changes
◦ Encourage cross training for team
members for understanding of RCM
processes (front desk , PA team
shadowing)
◦ Promote from within
◦ Have frequent staff meetings with key
players to inform them of progress or
issues billing team is tracking

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How to Avoid Claim Denials 2022 Updates

  • 1. HOW TO AVOID CLAIM DENIALS AND INCREASE REVENUE FAST STEPHANIE THOMAS CPC CANPC
  • 3. TYPES OF DENIALS • Front end edits: • Also called “Unbilled” “Code correct” “Pending with errors” • Clearinghouse edits: • Also called “exclusions” “clearinghouse rejected” • Denials • EOB denials, ERA reports
  • 4. FRONT END DENIALS 1. Demographic info 2. Internal coverage dates (ex policy termed 8/31) 3. Authorization info 4. NDC and quantity 5. Referral, referring NPI 6. General coding guidelines 7. ICD10 verification
  • 5. CLEARINGHOUSE DENIALS • Coverage/eligibility (more definitive) • Subscriber info (DOB, address, ID #) • Provider credentialing • Referrals • Authorizations • ICD 10 errors (unspecified, missing digits etc.) • MSP (Medicare secondary claims)
  • 6. EOB DENIALS Coverage and COB Authorization and referrals Global period Medical Necessity Non covered benefits Medical Records needed Credentialing (non- participating provider) Duplicate Claim lacks information
  • 8. MEDICARE APPEAL PROCESS • Reopening's • Allows for providers to correct clerical errors/omissions without having to request a formal appeal • Can be initiated via the following: • Telephone • In writing • Online portal • Examples of approved reasons for reopening • Billed amount • Rendering NPI and PTAN • Diagnosis (some exclusions apply) • Modifiers (some exclusions apply) • MSP type • CLIA numbers • Place of service • Unapproved reasons for reopening • Claim line additions and deletions • Year of service • Claims previously reviewed by redeterminations, Recovery auditor, recoupment or paid by another contractor • Billing provider information • Unlisted procedure codes
  • 9. Denial work/Appeal timeframes • Aetna • Most states are 180 days from initial claim determination • COB issues allow up to 24 months • Blue Cross • Appeals for Regence, Empire and Anthem can be done on Availity®, other plans have specific forms on their respective websites • Time limit is 180 days from initial determination date • Cigna • Specific form required • Include original EOB with request • Experimental and/or investigational denials must be appealed by patient/beneficiary • Workman's Compensation • Proceed with appeal letter. Include patient claim # and how treatment is directly related to compensable injury. Contact adjuster for additional info on denial. • United Healthcare • Submit appeal electronically using the Claims Reconsideration application on Link (preferred method) or utilize specific payer form • Time limit to appeal is 120 days after initial determination • Second level appeals must be filed within 60 days
  • 10. ADDITIONAL TIPS FOR SUCCESS Follow up 20 days after corrected claim or appeal submission to assure receipt, then every 30 days until paid Enlist the patient's assistance early with troublesome claims Keep a log of denials to track progress and learn denial trends Review coverage guidelines often for changes ◦ Encourage cross training for team members for understanding of RCM processes (front desk , PA team shadowing) ◦ Promote from within ◦ Have frequent staff meetings with key players to inform them of progress or issues billing team is tracking