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Claims Processing: Could My Claims Be Returned by the Insurance Company? Why?

Health Insurance Denied Form Showing Unsuccessful Medical Application

Claims can be returned for a variety of reasons. The most common cause for a rejected claim is missing or inaccurate information. For example, errors in patient data such as the date of birth, age, sex, address, or name will cause an immediate return. Then there is provider information and insurance identification numbers, which can be easily and unintentionally misrepresented.

When the insurance company payer receives a claim, they check to make certain the patient is covered by the policy and all treatment codes match the appropriate diagnosis. Sometimes preauthorization records, referring physician identification numbers, or evidence of medical necessity is left incomplete.

The use of a medical claims processing software ensures all required information is included in the claim, prior to submission to the insurance payer. The software will catch any obvious errors such as missing or invalid information easily. The best way to increase claim payments is through prevention, submitting a clean claim the first time without any errors.

A medical billing software solution is well worth your investment. Apex EDI wants to simplify claims processing for you, so you can get paid faster. Contact Apex EDI to watch a free demonstration of our software today.

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Claims Processing: What is Claims Adjudication?

After a medical claim is submitted, the insurance company determines their financial responsibility for the payment to the provider. This process is referred to as claims adjudication. The insurance company can decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider.

When an insurance companyAdobeStock_94630507 decides to reduce a payment to the provider, they have determined that the billed service level isn’t appropriate for the diagnosis or procedure codes. Therefore, it is important to ensure that all claims submitted for payment are coded accurately.

As soon as an insurance company receives a medical claim, they begin a thorough review. Sometimes even small errors such as a misspelled patient name may cause a claim to be rejected. This delay prevents you from receiving payment while corrections are made.

When claims are submitted electronically, the software can help prevent errors such as incomplete or inaccurate information before it is submitted for payment. This helps increase the speed at which you can be reimbursed for services.

Once claims are received by the insurance company, the review continues with detailed analysis of the insurance policy. Some claims are even checked manually by medical examiners who examine medical documentation to determine if procedures are medically necessary.

When the claim has passed through the review process, it can finally be paid. Having a claims processing partner, like Apex EDI, to prevent errors in claim submissions helps you get paid quickly. Contact Apex EDI to watch a free demonstration of our software today.

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Medical Claims Processing: Tips for Appealing a Denied Medical Claim

Denied Medical ClaimsMedical claims may be denied for a variety of reasons. Fortunately, there are some ways for patients to appeal a denied claim within six months of the healthcare service. Follow these tips and you will have better success recovering denied benefits from your insurance company.  

First, it’s important to understand exactly why the claim was denied. When an insurance company denies a claim they use codes to explain how they arrived at their decision. Look for the explanation of these codes in the explanation of benefits document (EOB) provided by the insurance company. If you need more information, call the insurance provider to ask specific questions.

Then, be sure to provide all missing information to the insurance company. You may need to write a detailed letter that includes your claim and policy number. If the insurance company provides a standard appeal form, be sure to answer all of the questions on the form completely.

If errors were made on the initial claim, provide the documentation needed to make the corrections. This may mean requesting that your provider resubmit information to the insurance company. Even simple, unintended, errors like misspelled names can cause a claim to be denied.

You will need to gather and organize all of the healthcare documentation to show that the services received were medically necessary before submitting an appeal. This includes medical history, prescriptions, referrals, and dates of service.  Apex EDI understands the claims process and the importance of keeping all of the medical information organized.

We work with providers and insurance carriers to minimize mistakes and incorrect denials. Contact Apex EDI for a free demonstration today. We are excited to help you out!

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Claims Processing: How to Avoid Claim Denials

Medical Claims Denial appeals formThe best healthcare practices know that managing claims and avoiding unnecessary claim denials is a crucial part of the business. Errors, oversights, and delays in processing can cause more  than you might think. To have an immediate impact on your business make improvements in these three areas.

All claims must be legible. Even claims printed electronically can get messy, smudged, or blurred from printers and scanners which can create a huge problem for payers. Payers must be able to read and scan claims into their system immediately upon receipt for you to get paid quickly.

Make sure all claims are detailed and specific about the care received by the patient. It’s uncommon for claims missing facts such as the date of the accident, emergency or onset of the medical condition to be denied. It’s important to answer each and every question on a medical claims form.

File all claims in a timely manner. This can get complicated to manage because each insurance carrier operates under its own guidelines and payment schedule. Carriers will deny claims that are simply not received within their payment window stipulated. When you are working with a number of different insurance carriers, you can quickly see the benefit of working with a medical claims processor like Apex EDI.  

Apex EDI works with providers to carefully manage insurance claims and make sure all filing deadlines are met for multiple payers. This allows you to get paid fast and stay focused on providing excellent patient care. Contact us at Apex EDI for a free demonstration today.

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Medical Claims Processing: What Does a Medical Claims Processor Do?

Caring for the health of your patients is the most important part of your business. That is why millions in the healthcare industry rely on specialized professionals, like Apex EDI, to manage the complex interactions between healthcare providers and medical insurance companies. Allowing others to handle this responsibility for you lets you focus your attention where it should be, on the patient.

When a patient seeks medical care, behind the scenes Apex EDI manages the transaction between the provider and the insurance company. We obtain a record of medical services provided from the office, clinic, or hospital and we handle the responsibility of sending healthcare claims out to the patient’s insurance company.

Medical Claims Process can be complicated

The medical claims process is a complicated, yet a crucial component to making sure you get paid accurately and quickly. The knowledgeable staff at Apex EDI understands medical coding, billing terminology, compliance requirements, common errors and the best ways to work with a variety of insurance providers from HMOs, PPOs to Medicare and Medicaid.

We know that payers can deny or reject claims when errors are made. We want to work

with you to help make sure your patient receives the best care possible, receives the insurance coverage they are entitled to, and you get paid in full. There’s nothing more frustrating than dealing with financial payment discrepancies during a health care crisis.  

Working with a medical claims processor can have a positive impact on your healthcare practice and your financial bottom line. Contact Apex EDI to request a free demonstration today.

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