Appealing a denied claim is a crucial part of the reimbursement process. While it may seem daunting, appealing denied claims can increase revenue and improve cash flow for your practice. In this blog, we'll explore the reasons to appeal a denied claim and the things you can't appeal.
Previously denied/closed as "exceeds filing time": If a claim was denied or closed due to exceeding the filing time, it may still be possible to appeal. Check the payer's guidelines for submitting late claims and follow their instructions carefully.
Previously denied/closed for "additional information": If a claim was denied due to missing or incomplete information, you can appeal by providing the required information. Make sure to follow the payer's guidelines for submitting the information.
Previously denied coordination of benefits (COB) information: If a claim was denied due to COB issues, such as primary insurance not being billed first, you can appeal by providing the correct COB information. Check the payer's guidelines for submitting COB information.
Resubmission of corrected claim: If a claim was denied due to coding errors or other mistakes, you can correct the errors and resubmit the claim. Make sure to follow the payer's guidelines for resubmitting corrected claims.
Previously processed but rate applied incorrectly: If a claim was processed but the payment amount was incorrect, you can appeal by providing documentation to support the correct payment amount. Check the payer's guidelines for submitting payment disputes.
Resubmitted prior: If a claim was previously submitted but denied, you can appeal by resubmitting the claim with additional information or corrected coding. Make sure to follow the payer's guidelines for resubmitting claims.
Bundled service: If a claim was denied because services were bundled, you can appeal by providing documentation to support separate billing for each service. Check the payer's guidelines for submitting bundled service appeals.
Things you can't appeal:
Patient cost-sharing: Patients are responsible for paying their share of the cost for medical services. Providers cannot appeal patient cost-sharing amounts.
Benefit limitation: Payers may limit coverage for certain services or procedures. Providers cannot appeal benefit limitations.
Benefit exclusion: Payers may exclude coverage for certain services or procedures. Providers cannot appeal benefit exclusions.
Membership issues: If a patient's insurance coverage has lapsed or was never in effect, providers cannot appeal the denial of the claim.
By understanding the reasons to appeal a denied claim and the things you can't appeal, you can increase revenue and improve cash flow for your practice. Make sure to follow the payer's guidelines for appealing denied claims and provide accurate and complete information to support your appeal.
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