Notations
These are the 5 questions needed to answer in a note.
What is, Who, What, Where, When, Why
What is the difference between a medical records request and reconsideration/appeal?
What is: medical records needed is to support the services rendered. Appeal/Recon is to fight an original denial decision using to documentation to support the argument.
When a claim is denied for no authorization, what 3 items are needed for review prior to appealing or pushing back with payer?
What is: Verify if auth was obtained and/or included on the claim, if auth was truly needed, or can a retro auth be obtained.
When Requesting or pulling medical records, what term that is referred to pulling the needed required documents?
What is "Minimum necessary required"
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When Calling an insurance company, the following is needed in the note to verify the call occurred.
What is Carrier Rep name, Claim number, Reference number
What is the preferred method to submit medical records?
What is: Payer portals
If the claim denies for medical necessity, and the balance is greater than $1,000 what process should be followed?
What is: Route the claim to Nurse Audit for a clinical review and possible appeal.
What are the first steps in reviewing an account for the first time, for a first placed account?
What is: 1. Review client notes for actions that have already occurred
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When following up on an account that has already been worked previously, it is important to do this first before beginning the next follow up.
What is Reading the previous notations
Once determined appeal is needed, what documentation (four possibilities) should be reviewed/included?
What is: Payer form (if applicable), appeal letter (if applicable), supporting documentation, and payer correspondence.
What denials are routed to Nurse Audit for review?
What is: Medical necessity
What does HIPAA stand for?
What is: Health Insurance Portability and Accountability Act
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What are the 3 main reasons notations need to be clear and concise?
What is 1. These notes can be used in a legal document for any legal issues regarding claims 2. These notes help tell a story of where the account is 3. it helps the next person working know exactly what needs to happen next
Why is it important to ensure the patient information matches all documentation saved?
What is: HIPAA
What four items support sending a timely filing appeal?
What is: Proof claim was originally submitted within timely, recoup performed extending the timely filing, payer delays in processing, and COB updates.
If a claim denies for medical records, and we show they were submitted multiple times with tracking or certified what is the next step?
What is: Call the carrier to verify if received, advise we have submitted multiple times, with tracking and that we need to speak to their Compliance officer due to HIPPA guidelines.
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What should not be in a notation?
What is 1. Credit Card information 2. names of people on the Aspirion team 3. Emotion or details regarding carriers that are negative
How long should Medical Records review be stepped out for?
What is: it should be stepped out to the following day, unless the next day is the weekend or a holiday. Then they step the account out to the next business day
When claim is denied for documents needed, what two important questions should be asked with the payer?
What is: What documents are specifically needed to overturn the denial, and what is timely filing to submit?
If a claim shows not on file, and we show it was submitted electronically, what is the next steps
What is, call the carrier to see if the claim has rejected
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What is Reeses Peanut butter cups