Assignment 4 – Medical Insurance Billing and Coding

Assignment 4

Often claims are denied because the right code is not used or information is omitted or in error. Other times, the claim is denied because the insurer did not understand fully the claim. Claims can and should be appealed if there is reason to do so and all other information is correct.

Your office has received a series of claim denials from one particular insurance carrier and you do not agree with the decision. You should consider appealing the denial. Go back and review the patient’s insurance card and verification form for coverage information. The explanation of benefits (EOB) letter from the health plan is the key to payment or denial status. If the coverage language supports payment, write an appeal letter describing the disorder and its medical nature, and reference the coverage policy paragraph that shows how your treatment fits coverage criteria. You may have to investigate coverage on the insurance website.

Forms You will need:

Insurance Cards (You should have already downloaded these for other assignments)

Verification forms (You should have already downloaded these for other assignments)

EOB’s

Expert Solution Preview

Question: What are some reasons why a claim may be denied by an insurance carrier?

Answer: Claims may be denied by an insurance carrier if the code used is incorrect, information is omitted or in error, or if the insurer did not fully understand the claim. Appeals can be made if there is reason to do so and all other information is correct. It is important to review the patient’s insurance card, verification form, and explanation of benefits (EOB) letter to determine coverage information and support payment. If coverage language supports the treatment, an appeal letter can be written referencing the coverage policy paragraph that shows how the treatment fits coverage criteria. Insurance websites may also need to be investigated to gather coverage information.

Expert Solution Preview

Introduction:

As a Harvard University Professor, I design and conduct lectures, evaluate student performance, and provide feedback through examinations and assignments. One topic that may come up in the healthcare industry is insurance claims and denials. In this Expert Solution Preview, we will discuss the reasons why a claim may be denied by an insurance carrier and the steps that can be taken to appeal the denial.

Question: What are some reasons why a claim may be denied by an insurance carrier?

Answer: Claims may be denied by an insurance carrier for several reasons. The first reason could be that the code used was incorrect, which is why it is essential to ensure that the appropriate code is used when submitting the claim. Another reason is that information was omitted or erroneous during the claim submission. This indicates the importance of double-checking all information before making a claim. Sometimes claim can be denied if the insurer did not fully understand the nature of the claim. Claims can be appealed if there are valid reasons to do so and all other information in the claim is correct.

It is critical to thoroughly review the patient’s insurance card, verification form, and explanation of benefits (EOB) letter to determine coverage information and support payment. The EOB letter is crucial in determining the payment or denial status, and if the coverage language supports the treatment, an appeal letter can be written referencing the coverage policy paragraph that shows how the treatment fits coverage criteria. Sometimes it is necessary to investigate the coverage on the insurance website to gather relevant coverage information.

In summary, it is vital to ensure that all information is correct and appropriate codes are used when submitting a claim. If a claim is denied, reviewing the EOB letter and verifying coverage information is crucial to determine whether there are valid reasons to appeal the denial.

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