When processing appeals there are typical processes each one goes though, as well as several accompanying challenges. First, before actual processing can occur, there is the challenge of differentiating appeals from other types of correspondence and identifying member vs. provider appeals. This determination drives a downstream workflow and any error can result in costly delays. Once determined, it is then imperative to issue timely acknowledgements, pay attention to differing turn-around-times, and be able to coordinate the association of supporting documentation.
Many appeals come in hand-written, which only adds to the time for determination due to potential poor legibility. There are also customer defined classification types, which are nuanced and easily subject to error, including corrected claims, provider disputes, third party liability, and itemized bills.
There are also tight deadlines for when acknowledgement letters should be sent out. If the identification of the appeals versus other correspondence takes roughly three or more days, you may have already missed the window for acknowledgement in certain jurisdictions.
Once you have sorted your documents out from other correspondence you must also determine if the appeal is in internal or external review to differentiate the turn-around-times (TAT) that are required for processing. Based on whether or not the service has been received you have 30-60 days to complete the internal review of the appeal. If denied, the appeal must be reviewed externally, and processed no later than 45 days after the request was received, unless expedited, in which it must be completed in 72 hours or less.
Submitted documents need to be associated with previously received collateral. The original claim and billing line from previous claim submissions and referral authorization must all be referenced. Additional collateral may be requested by the payer for the appealer. The originally received documents, claims, or appeals may be held in a pend queue while awaiting the requested collateral. These “holding tank” documents may be referenced when new collateral is received.
These challenges are common when processing appeals, however, Smart Data Solutions has a robust appeals processing workflow that can automate many of the timely manual processes to meet tight turn-around-times. To learn more about solutions offered, check out our website or call us at 651-894-6400 for more information.