Purpose of the General Appeals Process

Purpose of the General Appeals Process - redetermination....

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Purpose of the General Appeals Process Jessica Thibodeaux HCR/230 Barbara Hopkins When a claim is denied, reduced for payment, or down coded by the insurance company, or payer, the provider or the patient can file an appeal. The person who makes the appeal is known as the claimant or the appellant. An appeal must be done within a certain amount of time. Once the appeal has been made, the payer reviews the appeal to see what level the appeal is. Level 1 is a complaint, level 2 is an appeal, and level 3 is a grievance. If the appeal is denied, the appellant can take the claim to the state insurance commissions for review. The appeal process for Medicare starts with the review by an employee of Medicare that was not involved in the initial claim. The employee has 120 days to decide if payment should be made or not. The decision is sent as a letter and if denied a Medicare Redetermination Notice is sent to provider and the patient. If the patient receives this form, he or she has 180 days to file for
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Unformatted text preview: redetermination. This form is reviewed by a qualified independent contractor. If the claim is still denied, the claim can be sent to and administrative law judge. The amount of the appeal must be more than $110 and must be requested 60 days of receiving the reconsideration notice. The next step is the department appeals board. After receiving a response from the administrative law judge the claim must be sent to the department appeals board within 60 days. The last step is federal court. The amount of the dispute must be more than $1,090 and must be requested 60 days of receiving the department appeals board decision. Claims errors such as overpayments, underpayments, and incorrect codes occur often. These issues can be corrected easily but at times an appeal may have to be made to have them corrected if not caught before payment. References University of Phoenix. (Payment Processing). . Retrieved from University of Phoenix, HCR/230 website....
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Purpose of the General Appeals Process - redetermination....

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