Denial Management I

Denial Management

What is Denial Management:

It is a process in which if insurance company deny a claim, as a denial expert need to identify the exact reason, solve the issue and need to refile in order to get the payment on behalf of provider. Provider assign an expert who deal with insurance company to correctly process the claim and generate revenue for providers.

During this process we may come across the following scenarios and how to handle those denials; 

Claim Not on File or in system: 

• Verify the mailing address.
• Check in system whether we have sent it to the same address.
• Else get the correct address and send the claim to the new address.
• Check correct payer ID (incase of electronic submission)
• Verify the effective date of the policy for the patient.
• If patient is not effective for the DOS (DAte of Service) check in system whether the patient has any other insurance. If the patient has other insurance , call the insurance to verify the eligibility get the mailing address and filing limit and mail the claim or do the electronic submission.
• If patient does not have any other insurance flip the balance to the patient.
• Verify the filing limit for te carrier.
• If we are near the filing limit get the FAX number and "Attention". ANd fax the claim immediately.
• If we past the timely filing limit ask the representative (in short "Rep") whether we can submit the claim with proof of timely filing.

Claim pending for Additional information: 

• Ask the rep from when the claim is pending.
• Ask the rep additional information required from the patient or from the provider. 
• If its the provider, get what additional information they required. Example: Claim pending for Medical Records such as Office note, discharge summary, anesthesia reports etc
• Ask whether a request was sent to the provider , if so verify the mailing they sent to.
• Get the mailing address where the additional information needs to be sent to whether its the same claims mailing address or a different one.
• Get the filing limit for the information to be sent.
• If possible get the FAX number and "Attention".
• If the claim is pending for additional information from patient.
• Get what additional information is required from the patient.
• Ask the rep whether a request were sent to the patient regarding this.
• If so how many request were sent to the patient.
• Ask whether patient responded and the claim is still pending status ask the rep to send the claim for processing.
• If the patient had mot responded for the request, ask the sep how long the patient has time to respond back.
• If the project has patient calling access call the patient and inform the patient about the status of the claim. If not bill to patient.
• Get the claim number, received, denial date and call ref number.