How do I appeal a claim?

Healthcare providers may need to make an appeal for a claim to payers for a variety of reasons. One common reason is when a claim is denied due to a coding error. This can happen when the provider has used an incorrect code for the procedure performed or when the diagnosis code does not match the procedure code. Providers may also need to appeal when a claim is denied due to lack of medical necessity. This can happen when the payer determines that the service provided was not medically necessary based on the information provided. Other reasons for appealing a claim may include denials due to incomplete or missing information, incorrect patient information, or incorrect billing information. Regardless of the reason for the denial, it's important for providers to understand the appeals process and follow the necessary steps to ensure that claims are paid correctly and in a timely manner.

Steps:

1. Navigate to View/Edit Claim either through Manage Claims > View Claims (on a Rejected Claim alert) or Search.
2.  Once in View/Edit Claim, select the Other Actions dropdown on the top right of the screen and select Manage Appeals
   
3. A window will appear that provides some Appeal Options. 
   1. Select the appropriate Appeal Form in the dropdown. [This may only provide a generic appeal form option or it may include an appeal specific to the payer and a generic form option]
   2.  Select whether to include the Claim Form, an ERA, Claim History (notes and processes in Claim.MD related to the claim)
   3.  Select whether to include a PDF or Image by selecting Select files... button. 
   4.  Click  Generate Appeal when finished with options.
4.  The appeal form will display. Enter any required information indicated by red fields and boxes.
5. Click Continue
6.  Choose your Submission Method:
   1. Send Electronic Appeal:  In the circumstance where the payer accepts electronic appeals, a Send Electronic Appeals option will appear, accompanied by a field designated for the Payer Claim # (ICN). Conversely, if this method is not displayed, this indicates that the payer does not accept electronic appeals. Once the payer claim # is entered, click the Send Electronic Appeal button.
   2.  Send 1st Class USPS: This method means that Claim.MD will print out and send through 1st Class USPS all the claim information to the payer. 
      1. For this method, select the default payer address in the dropdown or enter the address information in the Mail TO field. 
      2. Click  Send Mail when completed.
         
   3.  Send Fax: In this method, enter the fax number and select the  Send Fax  button.
      1. An Appeal Status window will display the Fax To number, the attempts and the status if it was sent, failed, or aborted. The faxed appeal can be viewed by clicking the View button.
         
         
   4.  Manual Appeal: This method is meant for the user to download the appeal packet and send to the payer manually.
      Click Manual Appeal to download the PDF and print out or email the packet manually.