In most medical billing, the most effective first step in the appeal process is a phone call to the payer. Ask the representative if the problem can be solved; If not, find direction to start the appeal or reconsideration. If you're dealing with a commercial payer, the payer may reconsider form on its website that providers can use to challenge a payment decision.
Letter writing takes time, and then it takes more time for the recipient to read the letter, check the argument, and then sends the claim to be corrected. If the problem is simple, you may be able to have returned to just call the claim to the payer.
Before discussing the action with you, the provider representative - the person from the payer to work with you over disputes -verifies your need to know. Expect to ask the representative for the following information:
- Your name.
The name of your company and the VAT number or NPI number.
The NPI is the ten-digit number required by HIPAA to identify suppliers in electronic transactions.
- ID of the patient's name and date of birth.
- The date of the service in question.
- The invoiced amount of the claim.
After you check your need to know, you'll be able to tell the provider representative why the claim has not processed properly. Often, the agent can look at the claim, look at your contract, and determine what needs to be done. If that happens, the agent can usually return to send to the processor to process the claim with instructions again.
Sometimes, the phone call can alone be enough to solve the problem. If it does not, you should follow up with a letter.
Make sure you document all calls in the system or patient billing software. Watch who you talked to, what was the deal, and the reference number. This type of documentation is essential when a potential storage problem arises.