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HCR 230 Week 6 CheckPoint Purpose of the General Appeals Process

HCR 230 Week 6 CheckPoint Purpose of the General Appeals Process

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When a claim is down coded, reduced, or denied, the general appeals process can be used for challenging the payer’s decision. Patients and physicians alike may both request such an appeal. These appeals must be filed quickly once the claim has been denied or rejected (Valeruis, Bayes, Newby and Seggern, 2008). For example, if a claim is denied because of missing signatures, the claim must be fixed with the missing signatures and then resubmitted for the claim to be paid correctly. Billing errors are also reasons for claim denials. If a patient visits a special care provider but did not get the appropriate authorization before the visit, the claim might be denied, resulting in the providers need to appeal the claim (Jacob, 2001). Healthcare employees that work with billing and claims must be sure that all of the information they have for each patient is correct and up to date before to performing any procedure. Additionally, insurance
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Unformatted text preview: clerks have to be certain that they are using the proper procedure coded and not unintentionally over coding. Should a claim be denied, no matter the reason, it must follow the three steps of the appeals process: complaint, appeal and down coded. 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 (Valeruis, Bayes, Newby and Seggern, 2008). Reference Jacob, J. (2001). Amednews.com. Common coding errors can cost your practice. Retrieved May 14, 2011, from http://www.ama-assn.org/amednews/2001/07/02/bil20702.htm Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3 rd ed.). Boston: McGraw-Hill....
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