The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
Lifecycle of a Inpatient Claim
PRE-REGISTRATION Captures insurance data
Verifies insurance & eligibility Verifies patient demographics Obtains prior authorization Helps prevent prior authorization denials
REGISTRATION Re-validates patient demographics Verifies prior authorization was obtained Ensures timely notification of admission to payor Helps prevent prior authorization denials
CASE MANAGEMENT Verifies that patients meet medical necessity for inpatient status Performs timely, accurate, and thorough initial assessment and continued stay reviews Provides accurate information to payors Maintains compliance with mandated continued stay review frequency Helps prevent medical necessity denials
CLINICAL DOCUMENTATION INTEGRITY (CDI) Assures provider documentation reflects the patient’s clinical picture Helps prevent clinical validation, medical necessity, and coding denials
HEALTH INFORMATION MANAGEMENT (HIM) Maintains compliance with official coding guidelines Assures coding is supported by clinical documentation Submits clinical documentation queries Assures coding is performed to the highest level of specificity Helps prevent coding and clinical validation denials
PROVIDERS Provides care based on conditions and disease processes Assures accurate and timely clinical documentation Prevents clinical validation denials
BILLING Resolves edits Timely claim submission Accurate payment posting
APPEALS Monitors incoming denials
Ensures timely appeals Tracks appeals outcomes Adopts a zero tolerance policy for avoidable write-offs Helps prevent future denials through stakeholder education
Helps prevent technical denials from errors or omissions on claim form
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