Managing an Episode of Care

1. Managing an Episode of Care

2. Agenda Agenda – Managing an Episode of Care • Managing the patient encounter at the provider • The Insurance Claim • Lifecycle of a Claim • Submission • Processing • Adjudication • Payment • Managing Insurance Claims… • Denials/Appeals • Credit and Collections Confidential & Proprietary

3. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered • Insurance verification and eligibility • Patient and family counseling about insurance and payment issues • Patient and family assistance with obtaining community resources • Preauthorization of services • Capturing charges and posting payments • Billing and claims submission • Account follow-up and payment resolution Confidential & Proprietary

4. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered • Insurance verification and eligibility - front end staff verifying the patient does indeed have insurance with this payer and the front end staff identifies patient out-of-pocket responsibility – deductible, co-pay, co-insurance & out-of-pocket maximum • Patient and family counseling about insurance and payment issues – front end staff educates the patient about their benefits and their financial obligations, set up financial payment plans as well • Patient and family assistance with obtaining community resources – research financial resources and aid in identifying community resources to help with medical care • Preauthorization of services – contacting payers to obtain authorization for services before they are rendered • Capturing charges and posting payments – placing charges for service rendered into host or billing system, entering adjustments as well • Billing and claims submission – completing, submitting and processing claims • Account follow-up and payment resolution – reviewing eobs and remits, as well as account notes and resolving claim denials and rejections Confidential & Proprietary

5. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Insurance verification and eligibility - front end staff verifying the patient does indeed have insurance with this payer and the front end staff identifies patient out-of-pocket responsibility – deductible, co-pay, co-insurance & out-of-pocket maximum Step One: Preregister the new patient, obtaining the following information • Patient’s name • Home address and telephone number • Name of employer and employer’s address and telephone number • Date of Birth • Guarantor information (person responsible for paying the charges • Social security number • Spouse’s name, occupation and place of employment • Referring provider’s name – if there is one * remember for HMO – there must be if you are not primary • Emergency contact • Health insurance information Name & phone number of insurance company Health Insurance ID # Name of policy holder Health Insurance Group Number Confidential & Proprietary

6. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Insurance verification and eligibility - front end staff verifying the patient does indeed have insurance with this payer and the front end staff identifies patient out-of-pocket responsibility – deductible, co-pay, co-insurance & out-of-pocket maximum Step One: Preregister the new patient, obtaining the following information During this step, the medical reimbursement specialist must doing the following to insure that the provider receives the appropriate reimbursement for services rendered… • For a minor child, obtain the name, address and signature of the parent or guardian • Remind the patient to bring his/her health insurance card and photo id • Let patient know if the provider participates in their insurance plan • Participating provider – a provider that contracts with a specific health plan and accepts whatever payment the plan pays for procedures or services NOTE: a patient cannot be charged for the difference between the contracted rate and the normal fee 2. Providers who do not participate in the patient’s insurance plan will have to collect the difference between the normal fee and what the insurance plan pays Confidential & Proprietary

7. Managing an Episode of Care Example One: Northwestern Hospital is a participating provider in BC/BS of Illinois. Daniel goes to the ER at Northwestern. Daniel’s deductible has been met, but he has a $50 co-pay for ER visits. There is no co-insurance. Total Charges $1000 Contractual – 40% $400 Co-pay $50 Insurance payment Confidential & Proprietary

8. Managing an Episode of Care Example Two: Northwestern Hospital is not a participating provider in BC/BS of Illinois. Daniel goes to the ER at Northwestern. Daniel’s deductible has been met, but he has a $50 co-pay for ER visits. There is no co-insurance. Total Charges $1000 Usual and Customary rate (UCR) $800 Co-pay $50 Insurance payment $550 Patient payment $400 Confidential & Proprietary

9. Managing an Episode of Care Example One: Example Two: • Patient - $50 Patient - $450 • Insurance - $550 Insurance - $550 • Reimbursement - $600 Reimbursement - $1000 As you can see, if the patient utilizes an in-network provider rather than an out-of-network, their out-of pocket amount is lower. Out-of-pocket payment provision, which usually has limits of $1000 or $2000, dictates the maximum dollar amount a member has to pay for the year under their insurance plan. Once that amount has been met, the provider will include what had previously been part of the patient amount to the insurance company. Confidential & Proprietary

10. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Patient and family counseling about insurance and payment issues – front end staff educates the patient about their benefits and their financial obligations, set up financial payment plans as well Patient and family counseling about insurance and payment issues – front end staff educates the patient about their benefits and their financial obligations, set up financial payment plans as well Patient and family assistance with obtaining community resources – research financial resources and aid in identifying community resources to help with medical care Preauthorization of services – contacting payers to obtain authorization for services before they are rendered Step Two: Upon arrival for the office appointment, have the patient complete a patient registration form. Step Three: Photocopy the front and back of the patient’s insurance identification cards and the patient’s photo id. Confidential & Proprietary

11. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Step Four: Enter all information using computer data entry software. Verify all information is correct and make necessary changes (if old patient) Step Five: Verify insurance information and eligibility status with the insurance company by phone or computer – via payer website. Collect co-pay if applicable. During these steps, the specialist must complete the following… • Review of patient registration form • Verify information • Complete a Coordination of Benefits Confidential & Proprietary

12. Managing an Episode of Care Coordination of Benefits (COB) – provision in group health insurance policies that prevents multiple insurances from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim Primary versus Secondary Insurance: Primary insurance is the insurance plan responsible for paying healthcare insurance claims first. Once the primary insurance is billed and pays the contracted amount, the secondary plan is billed for the remainder and so on. BUT REMEMBER – group health insurance reimbursement cannot exceed the total cost of the services rendered! Generally, the patient is not always completely sure which policy is primary and which is secondary. But, there are some basic rules that every specialist should be aware of when processing claims. • Certain insurance policies are always considered primary to other plans. • If a patient has been in a car accident, the car insurance is always primary to health. • If a patient is injured on the job, the workers comp insurance is always primary to health. • Child living with both parents – birthday rule applies. However, some policies may use the gender rule – father primary. • Child of divorced parents – custodial parent’s insurance is primary. • Medicaid is always the payer of last resort; thus, if group policy, Medicaid is secondary. Confidential & Proprietary

13. Managing an Episode of Care Coordination of Benefits (COB) – provision in group health insurance policies that prevents multiple insurances from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim Primary versus Secondary Insurance: Primary insurance is the insurance plan responsible for paying healthcare insurance claims first. Once the primary insurance is billed and pays the contracted amount, the secondary plan is billed for the remainder and so on. Example One: A married couple has elected into both of their insurance plans. Jim works at IBM and has Humana, and Jane works at GE and has BC/BS. Jane’s birthday is in January, and Jim’s birthday is in June. What does the COB look like for Jane? For Jim? Example Two: Same example – only they have a daughter. Whose health insurance policy is primary their daughter? Confidential & Proprietary

14. Managing an Episode of Care Example Three: A patient is injured at work, but he also has group health insurance through this company. Which insurance is primary and secondary? Example Four: A patient has BC/BS, but they are also eligible for Medicaid. What is the coordination of benefits? Example Five: A five year old is brought into the ER. Her parents are divorced. Her mother has BC/BS. Her father has Humana. Her mother is the custodial parent. What is the coordination of benefits? Confidential & Proprietary

15. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Capturing charges and posting payments – placing charges for service rendered into host or billing system, entering adjustments as well Step 6 Create/pull medical record. Step 7 Generate a patient encounter form – this will vary by provider. At this point, the specialist hands the patient chart to the clinical staff who will document the episode of care. The clinical staff will return the chart once the episode of care is over so that the medical specialist can check the patient out and collect any patient payments. In addition, the specialist will schedule any additional follow up appointments. Step 8 Clinical staff assigns CPT, HCPCS, and ICD-9 codes to encounter form. Step 9 Enter the charges for procedures and/or services performed on the encounter form, and total charges on the encounter form. Step 10 Post all charges to the patient’s ledger/account record. Confidential & Proprietary

16. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Finally, we have reached the BACK END… • Billing and claims submission – completing, submitting and processing claims • Account follow-up and payment resolution – reviewing EOBS and remits, as well as account notes and resolving claim denials and rejections Confidential & Proprietary

17. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Finally, we have reached the BACK END… • Billing and claims submission – completing, submitting and processing claims Step 11 – Bill the patient’s insurance policy and then bill the patient for the coinsurance amount Step 12 – Post any payments that have already been made by the patient – co-pays, co-insurance; you should note where the payment came from, the date it was received, and how it was paid Step 13 – Complete the insurance claim Step 14 – Attach any supporting documentation – specialist may need to contact payer to see how they would prefer to receive the documentation Step 15 – If needed, obtain signature of provider – may not need if electronic Step 16 – Submit claim Confidential & Proprietary

18. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Finally, we have reached the BACK END… • Billing and claims submission – completing, submitting and processing claims During this step, the medical reimbursement specialist completes the following items. • The specialist may need to keep a copy of the submitted claim, if no electronic copy stored in a computer system, in the patient’s file • Bill the payer for total charges, either electronically or manually. If the claim goes out electronic, a provider may have a billing scrubber that holds claims for billing edits. Most of the time, these edits are standard, but a provider can implement customized edits. Edits will occur if the claim is not completed correctly. • Once the remit has been returned, bill the secondary or the patient. An EOB should probably be sent with these bills. Confidential & Proprietary

19. Managing an Episode of Care Accounts Receivable Management – This is, essentially, the REVENUE CYCLE Assists providers in the collection of appropriate reimbursement for services rendered Finally, we have reached the BACK END… • Account follow-up and payment resolution – reviewing EOBS and remits, as well as account notes and resolving claim denials and rejections During this process, a medical specialist will have to complete a number of tasks to get a claim to paid status. Confidential & Proprietary

20. Managing an Episode of Care Now to the claim… Confidential & Proprietary

21. The Insurance Claim Types of Claims • UB 04 – Facility Claim – used by facilities; such as hospitals, inpatient and outpatient clinics and ambulatory surgery centers to bill insurance companies for services rendered • CMS 1500 – Physician Claim – used to report professional and technical services rendered • Can be sent electronic or paper – if electronic, called the 837 How do the claim forms get populated? • UB 04 – Data from the hospital host system • CMS 1500 – Information from the superbill, patient record, or chart is transferred to claim form electronically Confidential & Proprietary

22. The Insurance Claim What is on an Insurance Claim – UB 04 or CMS 1500? Responses pertaining to patient’s condition and if related to employment, auto or any other accident, additional insurance coverage, or use of an outside laboratory and whether or not the provider accepts assignment • Patient demographics • Insurance policy information • Codes and charges for the patient encounter • Bill type • Patient’s signature – “signature on file” can be used as a substitute for patient’s signature, as long as real signature is on file Confidential & Proprietary

23. The Insurance Claim Let’s look at the claim form again… Confidential & Proprietary

24. Lifecycle of a Claim Confidential & Proprietary

25. Lifecycle of a Claim Claims Submission Electronic or manual transmission of claims data to insurance payers or clearinghouses • Claim is prepared from hospital host system • Claim data may be transferred to a standard format through the use of a clearinghouse or software • Clearinghouse is a public or private entity that processes or facilitates the processing of nonstandard data elements into standard data elements; they can also convert standard transactions (electronic remits) received from payers to nonstandard formats for the host system • VAN – value-added network – is a clearinghouse that also has value-added vendors, such as banks, that help with the processing of claims and handling transactions between providers and payers Confidential & Proprietary

26. Lifecycle of a Claim Claims Submission • Electronic Data Interchange (EDI) – the computer-to-computer transfer of data between providers and third-party payers or providers and third-party healthcare clearinghouses, in a data format agreed upon by sending and receiving parties There are three electronic formats supported for claims transactions • UB-04 flat file format • National Standard Format (NSF) • ANSI ASC x12 837 Format – remember 837 file out – 835 file in Confidential & Proprietary

27. Lifecycle of a Claim Claims Submission AMBA estimates that more than six billion insurance claims are filed each year, about 500 million claims a month, and of that number, approximately 40% are filed electronically with 60% filed manually Electronic claims submission reduces the number of denials by… • Reducing claims submission error rates to 1-2% • Increasing the number of clean claim submissions by sending claims through a billing editing process and correcting the claims electronically • Reduces the payment turnaround time through the shortening of the billing cycle The electronic claims can be transmitted through dial-up connection, internet, extranet and magnetic tape, disk or CD Confidential & Proprietary

28. Lifecycle of a Claim Claims Submission AMBA estimates that more than six billion insurance claims are filed each year, about 500 million claims a month, and of that number, approximately 40% are filed electronically with 60% filed manually The 60% that are filed manually must be printed and mailed to payer addresses. Downsides… • Extremely time consuming • Increased chance of claims being lost in the shuffle • Increased chance of claims going out with mistakes – no billing scrubber to check for missing information on UB or 1500 Confidential & Proprietary

29. Lifecycle of a Claim Claims Processing This process takes place at the payer or clearinghouse. It involves the basic validation of coverage and editing the claim to ensure that all required information is included on the claim form. If anything is missing on the claim form, the claim is rejected/denied and returned to the provider. If an insurance verification results in a fail, the claim is rejected/denied and returned to the provider. Reasons for initial denials… • Incorrect birthday on claim • No NPI number on claim • No authorization on claim • Fail of insurance verification Confidential & Proprietary

30. Lifecycle of a Claim Claims Adjudication After the claim has gone through the basic processing phase completed by a payer’s claim examiner, it undergoes claims adjudication. The claims adjudication process is where the claim is compared to the payer edits, (most likely done through computer software – similar to a billing scrubber) and the patient’s health plan benefits to verify all information is correct and all payer rules have been followed. Adjudication process involves… • Confirmation that the claim is not a duplicate • Payer rules and procedures have been followed • Procedures performed or services rendered are covered benefits • All required information has been provided to process the claim – medical records Confidential & Proprietary

31. Lifecycle of a Claim Claims Adjudication What does that really mean? The payer is now looking at the claim with a magnifying glass to identify any errors that would result in a denial. • What information or criteria do they utilize to deny a claim? • The common data file is an abstract of all recent claims filed on each patient • payer utilizes this information to understand if the patient is receiving concurrent care for the same condition by more than one provider • payer also utilized information to identify services that are related to recent hospitalizations, surgeries, and so on – Think Medicare 72 hour rule or transfer DRG! • The payer has a computerized database with information regarding all members and policies • if patient and subscriber names don’t match exactly or if there are typographical errors – claims will get denied • policy numbers are matched against each other as well Confidential & Proprietary

32. Lifecycle of a Claim Claims Adjudication What does that really mean? The payer is now looking at the claim with a magnifying glass to identify any errors that would result in a denial. • What information or criteria do they utilize to deny a claim? • Each policy has a master benefit list that is utilized to analyze data contained on claims • any procedure or service codes reported on claim will be bumped up against master benefit list to determine coverage • If a procedure is not on the master benefit list, it is a NON-COVERED BENEFIT. The member’s policy does not cover this service. A patient can be billed for these services. • procedures are also checked for authorization requirements • If authorization was not secured before procedure, it is an unauthorized service. Patients cannot be charged for these services. • If the patient has a managed care plan, both procedures and dates of service were performed within preauthorized time frame. • procedures are also checked for medical necessity Confidential & Proprietary

33. Lifecycle of a Claim Claims Adjudication • HOLY CROW…the claim has been approved. Now, during the adjudication process, a determination as to the allowed charges is made as well as calculations for the patient share of the bill. • The allowed charges for the claim is the maximum amount the payer will allow for each procedure or service. This will be based on the contract the payer has with the provider who is rendering the care. • Allowed charges are never greater than charges from the provide • The patient portion of a claim is broken up into a couple of different buckets Co-pay Co-insurance deductible Confidential & Proprietary

34. Lifecycle of a Claim Payment of Claims Once the adjudication process is completed, the claim is either paid, partially paid or denied. Payers then communicate this decision to both the provider and the patient. The payer also pays the provider their portion of the total charges. • The explanation of benefits is sent to the policy member. • Medicare calls this a Medicare Summary Notice. • The remittance advice, which can be sent electronically or by mail, is sent to the provider. • Medicare calls this a Provider Remittance Notice. • Based on the information contained in the remit, all payments are posted, all adjustments are made and a decision is made to either follow up on the claim, if there are any denials, or there is a final denial Note: payers include multiple patients on one remit Note: EFT is an electronic funds transfer – where the payer puts the funds in a provider’s account electronically – some sites may still have to manually adjust the accounts in cash posting; however most sites have the 835 functionality and the cash poster is acts as an auditor Confidential & Proprietary

35. Lifecycle of a Claim Payment of Claims What information is included on the EOB and Remit? • Third party payer’s name and contract number • Electronic data interchange information (EDI), including EDI number, date and time remittance advice was generated, and EDI receiver identifier • Provider’s name and mailing address • Adjustments applied to the submitted claim (e.g., reduced payment, partial payment, zero payment, and so on) • Amount and date of payment • Patient’s reference number, name and health insurance contact number, claim date, internal control number, allowable charges, deductible and coinsurance amounts, amount paid , and reasons explaining payment amount • Key Note: an explanation of benefits usually has this statement at the bottom or top… • This is not a bill. Confidential & Proprietary

36. Managing Insurance Claims Organization of Claims Most providers will keep claims for at least five years. Medicare Conditions of Participation require providers to keep information for five years; so there needs to be a system of organization to the records allowing for accurate and efficient managing of open claims. • Developing an organization system is key whether claims are filed electronically or manually! • Accretive organizes claims via risk level, payer, and facility for open claims • Most facilities hold all claims in imaging systems and utilize reports do identify open AR What do you mean there are open claims in this pile? I thought these were only paid claims! Remember: If a payer or patient requests information off of a remit; the specialist must remove all other patient data Confidential & Proprietary

37. Lifecycle of a Claim Payment of Claims State prompt payment laws and regulations require payers to pay within thirty days of receiving a clean claim unless the payer’s contract with the provider states something different. Once all information is received that is requested and the payer starts processing the claim, the thirty day clock begins again. Example: If the a clean claim is submitted on July 1 and is paid by August 1. Is this claim in compliance? Example: A claim goes out on December 15, but the claim is returned for missing information. The information is received on January 15, and the claim is paid on February 14. Is the claim in compliance? Confidential & Proprietary

38. Managing Insurance Claims Tracking Submitted Claims Once you have your organization system established. You must create a tracking system that allows you to stay on top of claim reimbursement. Remember to utilize the payer websites! • A good tracking system has the following characteristics… • Proper follow-up dates • Visibility to all open claims • Visibility and understanding of all denied claims and actions need • Status reports on all open claims • Way to track actions taken by previous specialists and the notes from their interactions • There are characteristics that drive successful follow-up. • Detailed-oriented • Organization • Strong computer skills • Persistence Remember to call payers! Confidential & Proprietary

39. Managing Insurance Claims Tracking Submitted Claims WOO-HOO!!! I got a remittance advice back from the payer. Some claims will be paid; other claims will be rejected for simple errors and still others may be denied. Remittance Advice/RA Received Claim Rejected Claim Denied Claim Paid Confidential & Proprietary

40. Managing Insurance Claims Tracking Submitted Claims CLAIM PAID Payments Posted Electronically/Manually Bill Secondary/Tertiary Bill Patient Collections Claim Paid Claim Denied Claim Paid Contact Patient Post Payments & Close out Account Close Account Begin Follow-up Confidential & Proprietary

41. Managing Insurance Claims Tracking Submitted Claims CLAIM REJECTED DX Errors &/Or Request For Information Resubmit Claim w/Errors Corrected Resubmit claim with Requested Information Remember – you will still need to track the claim as the payer may still deny the claim or request additional information. Confidential & Proprietary

42. Managing Insurance Claims Tracking Submitted Claims CLAIM DENIED Remember all claims need to be tracked until completely resolved. Once the account is completely resolved the account needs to be closed. • DX the claim • read notes in YBFU & Host • read the RA Decide on the appropriate action and take Document the action taken in your notes and indicate next steps Confidential & Proprietary

43. Managing Insurance Claims Working Rejections/Denials – Problems & Descriptions • medically necessary • pre-existing conditions • non-covered benefit • termination of coverage • failure to obtain preauthorization • out-of-network provider • lower level of care should have been provided • COB • duplicate claim • The point is there are a variety of reasons why an entire claim or a specific procedure can be denied. It is the responsibility of the reimbursement specialist to make sure the denial is accurate, and if it not, to research and build the case to get the claim or charge paid and the best possible reimbursement rate. Confidential & Proprietary

44. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Step One: Review the remit!!!!!! Step Two: Diagnosis the CLAIM!!! - Is there an error that needs to be corrected? - Is it a legitimate denial; and should we discuss with manager to take the appropriate steps to write-off the account? - Is there a request for more information? Step Three: Call the payer, but know your claim better than they do. The payer rep will know more about the policy adjudication, but you can know more about this specific claim. These are general steps for follow-up on a rejection/denial. Note that there will be additional steps based on the decision tree for the specific denial/rejection with variances based on payer and facility. Confidential & Proprietary

45. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Remittance advice indicates that the payment was denied for “medical necessity”. The payer has determined that the procedure performed or service rendered was not medically necessary based on the information submitted on the claim. • review notes • claim needs more documentation around necessity of services – this is a clinical issue • sending medical records may be enough, but more likely reimbursement specialist will have to send to clinical department Confidential & Proprietary

46. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Remittance advice indicates that the payment was denied for pre-existing condition. The payer has denied the claim based on the wording of the pre-existing condition clause in te patient’s insurance policy. A pre-existing condition is any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee’s effective date of coverage. • review notes • understand from payer who they want to verify that the claim is indeed referencing a pre-existing condition • calls to patient and payer may need to be made • research previous patient visits Confidential & Proprietary

47. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Remittance advice indicates that the payment was denied for non-covered benefits. The payer has denied the claim based on a list developed by the insurance company that includes a description of items covered by the policy as well as those excluded. Excluded items may include procedures such as cosmetic surgery or maternity benefits. • review notes • understand if the codes on claim are correct – so that if a call is made you are referencing correct information • calls to patient and payer may need to be made • this may be patient liability Confidential & Proprietary

48. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Remittance advice indicates that the payment was denied for termination of coverage. The payer has denied the claim because the patient is no longer covered by the insurance policy. • review notes • check for any authorizations • check payer website • contact patient to confirm correct insurance information Confidential & Proprietary

49. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Remittance advice indicates that the payment was denied for no authorization. The payer has denied the claim because no authorization or notification was made by the payer or to the payer. • review notes • check all systems for authorization or notes around notification • review encounter to understand if the procedure was a result of an emergency • contact payer to understand if there is an opportunity to obtain a retro-auth Confidential & Proprietary

50. Managing Insurance Claims Working Rejections/Denials Oh Brother, I have a claim that was denied by a payer…now what? Remittance advice indicates that the payment was denied for out-of-network provider or facility. The payer has denied the claim because treatment was received from a provider that is not contracted with the payer. • review notes • contact payer for the opportunity to write an appeal letter stating why care was sought by this particular individual or from this facility Confidential & Proprietary