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The Process of Appealing/Filing a Grievance for a Commercial Insurance Claim. Steve Verno. Disclaimer. I am not a lawyer! I don’t provide legal advice. This presentation is for training purposes only! Samples contain NO actual patient information. All names are fictitious!. NO GUARANTEES!.
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The Process of Appealing/Filing a Grievance for a Commercial Insurance Claim Steve Verno
Disclaimer I am not a lawyer! I don’t provide legal advice. This presentation is for training purposes only! Samples contain NO actual patient information. All names are fictitious!
We Will NOT Discuss! • ERISA! • HEALTH INSURANCE CONTRACTING
What we WILL Discuss! • Timely Filing Denials • No Authorization/Precertification • Payment Less than Billed Charges • Payment as a Non-participating Provider • Denied as a Non-participating Provider • Payment Sent to a Different Address • Claim is NOT paid or denied • Claim for Alleged Overpayment (Refund)
What we WILL Discuss! • Another Insurance is Primary (Refund) • Patient Never Revealed Medicaid Coverage • Third Party Liability • Information Not Received from Patient • Benefits Expired or Terminated • Seen Prior to Effective Date of Coverage • Bundled Service • Downcoding
What we WILL Discuss! • Information Requested from Provider not Received • Not a covered Service
STATUTES • FS 617.6131 AND 627.6131: (3) All claims for payment or overpayment, whether electronic or nonelectronic: • (a) Are considered received on the date the claim is received by the insurer at its designated claims-receipt location or the date the claim for overpayment is received by the provider at its designated location. • (b) Must be mailed or electronically transferred to the primary insurer within 6 months after the following have occurred: • 1. Discharge for inpatient services or the date of service for outpatient services; and • 2. The provider has been furnished with the correct name and address of the patient’s health insurer.
State Law • 641.513 Requirements for providing emergency services and care.— • (1) In providing for emergency services and care as a covered service, a health maintenance organization may not: • (a) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care.
State Law • 641.3156: A health maintenance organization must pay any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized by a provider empowered by contract with the health maintenance organization to authorize or direct the patient’s utilization of health care services and which was also authorized in accordance with the health maintenance organization’s current and communicated procedures, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.
The Benefit Manual • Your Benefits • Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. • Refer to the “Glossary” section for the definition of “medically necessary.” • Certain services must be precertified by XXXXX (name removed). Your participating provider is responsible for obtaining this approval.
Payment Less than Billed Charges/Payment as Non-Participating Provider
Payment Less than Billed Charges/Payment as Non-Participating Provider
State Law used by HMO • If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider.
State Law • Each health maintenance contract, certificate, or member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations not permitting treatment through the health maintenance organization’s providers, without prior notification to and approval of the organization. Not less than 75 percent of the reasonable charges for covered services and supplies shall be paid by the organization, up to the subscriber contract benefit limits.
