General Appeals Process Analysis

Purpose of the General Appeals Process

When a claim is down coded, reduced, or denied, the general appeals process can be used for challenging the payer’s decision. Patients and providers both have the ability and right to request such an appeal. These appeals have to be filed by a certain time once the claim has been denied or rejected (Valeruis, Bayes, Newby & Seggern, 2008). For example, should a claim be denied for the reason of missing signatures, the claim form has to be corrected with the missing signatures and then resubmitted for the claim to be paid correctly. Billing errors can also be reasons for claim denials or reductions. For example, should a patient visit the physician for an office visit but the insurance company receives a bill for a consult, the provider would receive payment just
If a patient visits a specialist but did not receive the required authorization prior to the visit, the claim may be denied, resulting in the provider’s need to appeal the claim (Jacob, 2001). Healthcare employees who handle billing and claims must be certain that all of the information they have for each patient is correct and up to date, and that they receive all necessary authorizations prior to performing any procedures. Additionally, insurance clerks have to be certain that they are using the proper procedure codes and not unintentionally over coding. Should a claim be denied, no matter the reason, it must follow the three steps of the appeals process. These three steps are complaint, appeal, and grievance. By filing an appeal, the claim can be paid when it was previously denied, reduced, or down coded. After the appeals process and decision, if a provider or patient is still not satisfied, the appeal can be taken to an outside authority, like a state insurance commission