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What are the Right Documents to File Denied Claims?

May 18, 2015


Denied claims

According to the American Association of Retired Persons (AARP) about 200 million claims get rejected every year for myriad reasons. Hence, when a claim is rejected there are several ways that it can be cleared. One of the most important things to do when a claim is denied is to keep on re- applying. The reason for this is the insurance company is trying to spread the risk and keep the money with them as long as possible. Hence, if one keeps on re-applying the chances of the claim getting cleared are higher.

The Department of Labor estimates that about one claim in every seven claims made under the employer health plan that they oversee are initially denied.

Industry Snippet

The US insurance industry is at a revenue of about $731 billion. Characterized by a slow annual growth rate of a shade fewer than 3%. This might throw light on the fact why insurance companies are trying to deny or delay payments. A slow market means business is not growing but claims keep on coming. Hence the only way out for them is to either deny paying the claims or keep on delaying them. It is to be seen if the increase in health expenditure and the aging population helps in reviving the industry or it impairs the growth further.

Documents required to file denied claims –

In the event that the claim gets denied the provider needs to ensure following documents are kept ready for re applying:

  • The health plan and any kind of correspondence pertaining to it with the insurance company needs to be kept ready
  • A copy of the standard or requirements copy which is used by the insurance company and any other document related to the denial which is also known as a claim file needs to be kept ready for re-applying
  • Copies of medical records
  • A letter from the healthcare provider stating why the requested treatment meets the health plans definition of medically necessary

Steps to be taken to appeal a denied claim

After preparing the documents these are the steps one can take to appeal denied claims:

  • One must analyze the reason why the claim got denied
  • If the claim got denied for reasons like a misspelt spelling then straighten that out either through the provider and ask them to resubmit or request the payer to modify it and then proceed
  • Preparing and submitting the correct paperwork is extremely essential
  • Resubmitting the claim within the stipulated timeline
  • Make sure that you are courteous to the person who informs you that the claim is denied. After all it is not the messenger’s fault that your claim is getting denied
  • In case of repeated denials it would be prudent to apply to an external agency who would look in to the matter
  • In case of an emergency, where medical treatment needs to be given it would make sense to apply internally with the insurance company as well as with the external agency simultaneously to get the claim processed faster

In case if it becomes a bit too much to look in to the denials; get in touch with MedicalBillersandCoders.com; their team of expert professionals will help you in getting your claims cleared and streamline the process so that denials get reduced.


Category : Accounts Receivables / Claims Denials