Often claims are denied because the right code is not used or information is omitted or in error. Other times, the claim is denied because the insurer did not understand fully the claim. Claims can and should be appealed if there is reason to do so and all other information is correct.
Your office has received a series of claim denials from one particular insurance carrier and you do not agree with the decision. You should consider appealing the denial. Go back and review the patient’s insurance card and verification form for coverage information. The explanation of benefits (EOB) letter from the health plan is the key to payment or denial status. If the coverage language supports payment, write an appeal letter describing the disorder and its medical nature, and reference the coverage policy paragraph that shows how your treatment fits coverage criteria. You may have to investigate coverage on the insurance website.
Forms You will need:
Insurance Cards (You should have already downloaded these for other assignments)
Verification forms (You should have already downloaded these for other assignments)
Expert Solution Preview
Question: What are some reasons why a claim may be denied by an insurance carrier?
Answer: Claims may be denied by an insurance carrier if the code used is incorrect, information is omitted or in error, or if the insurer did not fully understand the claim. Appeals can be made if there is reason to do so and all other information is correct. It is important to review the patient’s insurance card, verification form, and explanation of benefits (EOB) letter to determine coverage information and support payment. If coverage language supports the treatment, an appeal letter can be written referencing the coverage policy paragraph that shows how the treatment fits coverage criteria. Insurance websites may also need to be investigated to gather coverage information.