Question

Explain the limited role of a provider in executing an appeal to a third-party payer in response to an invalid denial or refund request from the insurance company (or their representative).

Answer 1

if the provider has no contract with the provider ,the provider is not obligated to the carriers deadline ,Their denial should be appealed and payment demanded.The claims can be denied because of lack of insurance coverage,selected diagnosis not covered,frequency limitations,procedure performed by ineligible speciality provider,bundled with other services,payable only in certain locations and missing or incorrect service code.TheT health care provider sends the claim to the third party payer requesting payment .Submissions are made electronically and the roleof the health care provider comes into the final stage of Reconcilation.In this process the health care provider analyzes recieved payment information compared to submitted claim information for accuracy.if the provider believes a claim was inappropriately denied by the payer,the dispute process begins until satisfactory reconciliation is achived by the provider and the third party payer.