Dealing with Health Insurance Documentation & Problems
Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 7
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The insurance company had a limited number of computerized codes that personnel could choose from when processing a claim. The company had a code that printed the words "not medically necessary" on an EOBS, but there was no computer code to print a statement such as, "We need an operative report and a detailed hospital bill before we can process this claim further." There apparently wasn't even a computer code to print the words "Insufficient documentation."
According to the insurance company supervisor, the company's records indicated that several letters had been sent requesting the required documentation, but that there had been no response. Thus, the claim had been placed temporarily on hold. However, when I discussed the issue with the doctor and with hospital representatives, they were certain that they had never received any requests for additional information or documentation.
Once the problem was clear, it was a simple mailer to ask the doctor and the hospital to fax the appropriate documentation directly to the insurance company supervisor and to ask the supervisor to have the claim reviewed as quickly as possible. Once that process was completed, the claim was ap proved for payment within 48 hours.
After the problem had been solved, I had an opportunity to discuss the case with an executive at the insurance company. He was not aware that the company was printing a "not medically necessary" statement on the EOBS when the documentation was incomplete, and he agreed to make certain that additional computer codes were added to allow other, more appropriate, messages to be printed in the future.
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