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When to File an Appeal in Medical Billing

As a medical billing professional, it is good to know some general guidelines for when to file an appeal. After you submit a claim to the payer, you can expect a response within 60 days. Often, larger payers respond within 15 days. If everything goes ideally, the payer processes the claim as you anticipated, and the payment is correct. If either of these doesn’t happen, you need to follow up.

When general follow-up doesn’t yield a timely payment

Following up may be as simple as calling the payer to see whether the claim has been received and where it stands in the adjudication process. (Adjudication refers to the payment obligation outlined in the patient’s insurance benefits.) Sometimes, the claim isn’t there, and you need to resubmit it and start the calendar again. Other times, the payer may need additional information from your office, another provider, or the patient.

If the payer needs information from your office, you can provide it simply enough. If he needs info from another provider, you may need to contact that other provider to see whether the payer’s request has been received and whether the provider has responded. If information is needed from the patient, you probably need to contact the patient and ask her to contact her insurance company.

When mix-ups in accounts receivable result in a delay

Accounts receivable (AR) is the name for outstanding payments. All companies monitor how many days their accounts have been in AR. For most companies, 90 days is tolerable, but going beyond that gets undesired attention from above. Outstanding AR can be a result of a slow payer, and most contracts contain language that obligates payment within a certain time. Many states have prompt pay statutes aimed at preventing claim stalling.

Often the cause of a high number of accounts receivable days is that the payer has not paid as expected. Claims processors use claim adjudication software to price claims. For payment to occur in a timely manner, the correct contract must be loaded for each claim. Sometimes, that doesn’t happen, and the claim doesn’t process according to contract. At that point, you must appeal the claim.

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