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    Insurance denials and appeal

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    What is an appeal?
    What are some reasons why a claim may have been denied but can be appealed? Include 5 examples.
    Why is an appeal important?
    Is that the next step your friend should take?

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    Solution Preview

    Hope this helps you.

    An appeal can be defined as a request to review a decision (Merriam-Webster, 2011). In healthcare, is also an action that the person can take when a claim has been denied, not paid enough, or the health care service rejected by the insurance (Medicare.gov, 2011).
    An appeal is a very important asset that the provider or patient has as it provides the opportunity to recuperate payment for services provided. There are certain situations when there will be a need to appeal in writing to the insurance. For example,

    A)Denied for wrong diagnosis/modifier/procedure
    When the insurance receives a claim, it is automatically review to match the CPT code provided with the ICD9. If the diagnosis does not support the procedure, the claim will be automatically rejected. This also happens when the wrong modifier is used. These claims can be resubmitted as corrected claims but sometimes the insurance may request to send the corrected claim as an appeal that will provide additional information (and a copy of the medical record) that justifies the corrected ...

    Solution Summary

    The solution involves a discussion on five common types of reasons why you can get a health insurance denial of payment. It also describes how it happened and the way to resubmit or if necessary appeal it.