How to Win at a Claim Denial From an Insurance Company

Medical coders advocate for patients who hold less authority.

For health service providers, receiving a denial on a request for payment from an insurer creates work outside of routine billing. It's not impossible for a claim to go unpaid. However, most providers choose to exhaust the appeals process to prevent loss, especially for services over $500. An appeal is a request to have the insurer reconsider a denied claim; there are several tiers in the insurance appeals system.



Medical coders, data entry clerks responsible for billing for doctors and clinics, are the first tier of the system. It is the coder's responsibility to audit the denied claim according to federal mandates after receiving the explanation of benefits (EOB) from the patient's insurer. The coder advocates for the patient.

Things You'll Need

• EOB (explanation of benefits)
• Insurer's customer service phone number
• Claim number

Instructions

1. Check the EOB for the denial code. Use the denial code to determine what action needs to be taken to have the claim paid. If the denial code needs to be explained further, contact the insurer's customer service department.

2. Verify that the recipient number and other personal identifiers for the denied claim match the identifiers on the appeal. If the identifying information does not match, complete research to find the correct recipient.

3. Correct the CPT and ICD-9 codes if the claim was denied for incorrect usage. CPT codes describe the procedure completed by the provider of care, while ICD-9 codes codify the condition causing the need for service. If claim denial requests prior authorization from the insurer, contact the insurer's customer service line to verify which documentation is needed.

4. Record the date the appeal is mailed out of the office. Ensure that the appeal is mailed out within 180 days after receiving the denial from the insurer.

5. Verify that the correct address for appeals processing is used. In most cases, appeals should be mailed to a different location from the one used for initial processing.

Tips & Warnings

• Check annual publications from the Agency for Health Care Administration (AHCA) to ensure proper CPT and ICD-9 codes are used. The codes are specific, but can change. Also, watch out for updates on other billing issues presided over by AHCA.

• The insurer has as long as 20 business days from the date of receipt of the claim to pay or deny the claim. If you have not received an EOB, call the insurer's customer service line to ensure the claim was received.

• HIPPA law prohibits the abuse of shared information. HIPPA is the Health Information Portability and Privacy Act. For insurance billing, HIPPA requires that personal identifiers remain sealed. Do not discuss or display CPT and ICD-9 codes or personal identifiers with unauthorized personnel.

References

• Local Medical Review Policy: Medical Glossary
• Maine Bureau of Insurance Brochure: Guide to Health Insurance Appeals Process