Avoid Appeal in Medical Claim Denial will allow the service to process as expected, reducing the need to make
changes after the claim has processed.
How to avoid Appeal in Medical Claim Denial [Tips] |
Tips to Avoid Appeal in Medical
Claim Denial:
• Should be intimately familiar with
local coverage determinations (LCD)
• Should be with familiar with the
national coverage determinations (NCD)
• If necessary, add a modifier to
the services. Failure to add a modifier would result in rejection.
• Documenting a repeat or duplicate
service to reflect this is a separate and distinct service. Failure to document
a repeat or duplicate service will result in denial of service.
• Provide the supporting documents
with the claim, if a certain modifiers [e.g] Modifier 52 (or) Modifier 22 are
appended to the service (or) if the LCD or NCD suggests that the documents are
needed. Failure to request the documentation would result in a denial.
• Compliance with supporting
documentation requests. Failure to meet with the request would result in a
denial.
• The supporting documentation must
include the signature of the rendering physician. Failure to have a valid
provider signature will result in denial.
• Include a concise description of
the unlisted procedure code (NOC code) or the "not otherwise marked"
code. Failure to describe the NOC or other scenarios listed below will lead to
denial.
• If Medicare is a secondary payer
(MSP), the claim should include details from the primary insurance carrier.
Failure to include this information will lead to denial.
Please verify that all below
details relating to the service are accurate to avoid Appeal in Medical
Claim Denial. The right information helps the service perform as planned; removing
the need to make changes after the claim has processed,
- NPI of Billing Physician
- Assignment or Non-assignment of claim
- Health Insurance Number (HIC) of the beneficiary
- Zip Code of the place of service
- All related diagnosis reported with the highest degree of specificity
- NPI of Referring Physician
- Date of service
- Place of service
- Procedure code
- Modifiers when applicable
- Number of services (s)
- Billed amount for each service
- NPI of Rendering Physician
- Clinical Laboratory Design Adjustment Number (CLIA) for laboratory facilities
- The Date last saw/X-ray date, original treatment period for Podiatry, Physical Therapy, and Chiropractic Services.
- Primary payer data
The conclusion to Avoid Appeal in Medical Claim Denial:
The LCD is a recommendation by the
Medicare insurance whether to cover a particular item or service. LCDs provide
accurate and appropriate details and are administrative and instructional
resources that support you in the filing of correct claims for reimbursement.
LCDs can be visible on the website
of the Novitat Solutions Medical Policy Center. Be acquainted with the National
Coverage Determinations (NCD).
The National Coverage
Determinations Manual specifies how different medical items, facilities,
medication procedures (or) technology will be payable under Medicare.
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