Electronic Claims Submission & Claims Submission Management

Definitions

Denied Claim: A claim rejected for payment after adjudication by the insurance payer.

Rejected Claim: A claim not accepted for processing due to submission errors.

Appeal: A formal request for reconsideration of a denied claim.

Procedure

1. Denial Identification

1. Review all Explanation of Benefits (EOBs), Electronic Remittance Advice (ERA), and payer correspondence daily.
2. Log denied claims into the Denial Tracking System within one business day of receipt.
3. Categorize denials according to payer denial codes.

2. Denial Classification

Denials shall be classified into one of the following categories: eligibility or coverage issues, authorization or referral issues, coding errors, documentation deficiencies, timely filing issues, medical necessity denials, duplicate claim denials, coordination of benefits issues, and other payer-specific denials.

3. Root Cause Analysis

1. Review the claim, medical record, and supporting documentation.
2. Identify the cause of denial.
3. Determine whether correction, resubmission, or appeal is required.
4. Document findings in the denial tracking system.

4. Corrective Action

A. Correctable Billing Errors

Correct demographic, coding, modifier, or payer information; resubmit claims according to payer guidelines; and document all corrections and submission dates.

B. Documentation-Related Denials

Obtain missing records or provider documentation, verify medical necessity documentation, and submit a corrected claim or appeal package.

C. Eligibility or Authorization Denials

Verify patient insurance information, confirm authorization status, and request retroactive authorization when permitted by payer policy.

5. Appeal Process

1. Prepare appeal within payer filing deadlines.
2. Include an appeal letter, a copy of the denied claim, medical records, authorization documentation (if applicable), and supporting clinical evidence.
3. Submit appeal through payer-designated channels.
4. Record submission date and confirmation number.

6. Follow-Up

1. Monitor appeal status every 14 days or according to payer guidelines.
2. Contact payer representatives when necessary.
3. Escalate unresolved appeals after 30 days.
4. Maintain detailed communication logs.

7. Escalation

Claims may be escalated when multiple appeals have been denied, when payer response exceeds contractual timelines, when high-dollar claims remain unresolved, or when regulatory or compliance concerns are identified.

Escalation may include supervisor review, provider involvement, payer management contact, and external review, when applicable.

8. Resolution and Closure

A denial case may be closed when payment is received, when final appeal rights have been exhausted, when the claim adjustment has been completed, or when the provider authorizes a write-off. All outcomes must be documented in the denial tracking system.

Quality Assurance

Conduct monthly denial trend analysis, identify recurring denial patterns, implement corrective training and process improvements, and report denial rates and recovery metrics to management.

Performance Standards

Denials are reviewed within 1 business day of receipt, appeals are submitted within payer deadlines, follow-up is conducted at least every 14 days, and all denial activities are documented in the billing system.

Record Retention

Denial records, appeals, and supporting documentation shall be retained in accordance with payer contracts, state regulations, and organizational record retention policies.