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    Denial Management Handbook

    Uploaded by

    nandyboy
    The document is a handbook for managing denied medical claims. It provides information on common types of denials including soft denials that can be resolved without appeal, hard denials requiring appeal, and preventable denials caused by provider error. It describes clinical and administrative denials and reasons for denials such as medical necessity, coding errors, missing information, and non-covered services. The objective is to help associates resolve denials using available resources without having to contact the payer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Denial Management Handbook

    Uploaded by

    nandyboy
    2K views5 pages
    The document is a handbook for managing denied medical claims. It provides information on common types of denials including soft denials that can be resolved without appeal, hard denials requiring appeal, and preventable denials caused by provider error. It describes clinical and administrative denials and reasons for denials such as medical necessity, coding errors, missing information, and non-covered services. The objective is to help associates resolve denials using available resources without having to contact the payer.

    Original Description:

    RCM - Denial Management Handbook

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    © © All Rights Reserved

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    The document is a handbook for managing denied medical claims. It provides information on common types of denials including soft denials that can be resolved without appeal, hard denials requiring appeal, and preventable denials caused by provider error. It describes clinical and administrative denials and reasons for denials such as medical necessity, coding errors, missing information, and non-covered services. The objective is to help associates resolve denials using available resources without having to contact the payer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views5 pages

    Denial Management Handbook

    Uploaded by

    nandyboy
    The document is a handbook for managing denied medical claims. It provides information on common types of denials including soft denials that can be resolved without appeal, hard denials requiring appeal, and preventable denials caused by provider error. It describes clinical and administrative denials and reasons for denials such as medical necessity, coding errors, missing information, and non-covered services. The objective is to help associates resolve denials using available resources without having to contact the payer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5
    At a glance
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    The key takeaways are that the handbook aims to help associates resolve denials in their accounts receivable inventory without having to call the payer. It discusses different types of denials like soft, hard, preventable/avoidable denials and their definitions.

    The purpose of the handbook is to help associates address denials in their AR inventory using available resources without having to call the payer.

    The different types of denials discussed are soft denials, hard denials, preventable/avoidable denials, clinical denials, and technical or administrative denials.

    Denial Management Handbook

    Table of Contents
    Page 1|5
    NO TABLE OF CONTENTS ENTRIES FOUND.

    Page 2|5
    1 Preamble

    1.1.1 Objective
    Purpose of this handbook is to help the associates address the denials in their AR inventory with the available
    resources to the maximum extent possible without having to call the payer.

    1.1.2 Target Audience


    Associates working in the 01 to 10 shift. This would also assist the Day AR associates in resolving accounts
    without having to handoff to the Callers to a large extent.

    Page 3|5
    2 Denial Management
    2.1.1 Definition
    Denial of a claim is the refusal of an insurance company or carrier to honor a request by an individual, or his or her
    provider, to pay for a health care services obtained from a health care professional.

    2.1.2 Common Denial Types


    Soft Denial
    A temporary denial that has the potential to be paid if the provider takes effective follow-up action.
     Appeal not required, Examples:
    o Pending receipt medical records
    o Denied due to missing or inaccurate information
    o Coding or charge issues
    o Pending itemized bill
    o Pending receipt of invoice

    Hard Denial
    A denial that results in lost or written-off revenue.
     Appeal is required, Examples:
    o No pre-authorization
    o Not a covered service
    o Bundling
    o Untimely filing

    Preventable or Avoidable Denial


    A hard denial resulting from action or inaction on the part of the provider of services
     Usually involve elective services that could have been delayed or deferred
     Account for about 90 percent of denials, Examples:
    o Registration inaccuracies/Ineligible for insurance
    o Invalid codes, Medical necessity
    o Credentialing

    Page 4|5
    Clinical Denial
    Denials of payment on the basis of medical necessity, length of stay or level of care.
     May be concurrent (while patient is still in-house)
     or retrospective (after the patient is discharged)
     Typically begin as a soft denial
    o Delay of payment where further medical or clinical clarification may be required

    Technical or Administrative Denial


    A denial in which the payer has notified the provider, by way of remittance advice, with specific information
    describing why the claim or item was denied.
     Typically done via remark code or reason code
     Includes delay of payment where additional documentation is needed
    o Coding clarification
    o Requests for medical records
    o Itemized bills

    The majority are administrative in nature


     Missing information
     Inaccurate information
     Time span issues (dates of services, authorizations)
     Ineligible patient, service or provider
     Coding errors with diagnosis, patient identifier #, NPI (provider identifier), procedure code

    2.1.3 Reason for Denials


     Medical necessity
     Missing or invalid CPT or HCPCS code submitted
     Incorrect patient identifier information submitted
     Spelling of name, DOB, subscriber number missing / invalid, insured group number missing /
    invalid
     Procedure/surgery requires prior authorization or precertification
     Place of service does not match surgery/procedure performed
     Claim submitted for non-covered service

    Page 5|5

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