General Guidelines
This is what the explanation of benefits must reflect in order to proceed with an appeal.
What is the corresponding denial reason or short payment?
What is a non-contracted payer?
For this type of authorization denial, we will forego contacting the facility and move with a medical necessity appeal unless the plan is for UHV or TWV.
What is No Initial Authorization (NIA)
We should still call to follow-up with an insurance after two weeks even if this number shows that an appeal is still in transit?
What is the Cert/Tracking number?
This status code should be utilized for all appeal requests.
What is status code 515?
This document number, which is used to locate the rate and policy information for an insurance agreement, is needed in an appeal note.
What is a contract number?
What is Not Recognizing Auth (NRA)?
Appeals are mailed from the BSO by this team.
Who are Shared Services?
This Activity Code must be used for appeal requests.
What is A/C 430?
This is the limitation deadline of when we can appeal an insurance decision.
What is timely filing?
This number, which is always required for corrected claims, must also be added for an appeal request note.
What is the document control number (DCN)/ claim number?
This is when we should remove the level 2 APSB PIC after a favorable decision is received.
What is once a payment posts?
This is where any additional documents that cannot be pulled by Shared Services must be found prior to an appeal request.
What is IPScan?
This amount, which should be the bucket balance for the insurance we wish to appeal, must be added to our appeal request note.
What is the short payment amount?
We use this code when an insurance has recouped their payment even after we've provided a refund.
What is Refund/Recoup (RFRC)?
This is what we should do once we confirm the appeal was not received and sent to the incorrect address.
What is re-request the appeal following the appeals checklist and provide the correct appeal address?
This person must scan in documents if they are not found in IPScan or Cerner.
Who is the collector/ARA?
This is the plan promised amount, or what the payer was expected to pay, and must be entered in the appeal request note.
The contracted rate
If we have initially booked an account with an insurance, but later determine another payer was primary during the patient's treatment, we would use this PIC to identify the authorization issue.
What is NACI (No Auth-Changed Insurance)?
If an appeal is not needed, this person/position will update the account status to 501 for review of other options or steps.
Who is the Sr. ARA?