How To Appeal A Denied Claim

The easiest way to appeal a denied claim, if you use Healthy Bytes, is to contact your dedicated claims expert and rest easy.

If you haven't made the switch yet and still have to appeal your own claims, here's what we recommend.

In a previous post on Eligibility Estimates, we advised you to ALWAYS get a reference number at the end of a call because it can help with denied claims. Today, we'll discuss what to do when your claim is denied and how that reference number may come in handy.

Step 1: Figure out why the claim was denied

The first thing you should do when you see a denied claim is call the insurance company. The information you'll need for the call is similar to an eligibility estimate:

  • Your NPI/tax ID
  • Patient's ID
  • Patient's name and date of birth
  • Service date of the denied claim

Once you get hold of a representative (he can give you more information than the automated voice system), just ask him to check the status of the claim and why it was denied. Make sure to get as much information as you can about why it was denied so you can re-file it correctly and get paid! 

Step 2: Fix the Problem

There are numerous reasons why claims are denied. Here are some of the more common ones we run into: 

  • A simple mistake made on the form: you accidentally put the diagnosis code as Z73.1 instead of Z71.3. The claim will most likely be denied because the code is incorrect/un-billable. 
    How To Fix It: Get the number (often called the Payer Claim Control Number or Claim Reference Number) of the original claim and refile a corrected claim with the right information.
  • Medicare is the primary insurance: The claim will be denied with the secondary insurance.
    How to Fix It: You can either 1) try filing with the correct modifier (GA or GY) or 2) first submit the claim to Medicare to be denied and then send that EOB to the patient's secondary insurance. We know it's a pain, but the secondary insurance needs to see that Medicare won't cover the costs. 
  • The code is not a billable service: Essentially, the CPT codes or diagnosis codes (or both) are not covered under the patient's plan.
    How to Fix It: This can't be fixed, but it can be avoided in the future by performing an eligibility estimate. 
  • The claim amount went towards the dollar deductible: Technically, the claim is not denied, insurance just won't cover the patient yet.
    How to Fix It: Again, an eligibility estimate can prevent this surprise by checking how much of the deductible has been met.

Why you may need that reference number: On occasion, you'll get the wrong information during an eligibility estimate, or the claim will be wrongfully denied. Did the claim go towards the dollar deductible when you were told the deductible didn't apply to nutrition services? Then call the insurance company and provide the reference number of the eligibility estimate. They can go back to the notes or recording of the eligibility estimate and review the claim. 

Note: It's good to remember that corrected claims or claims under review can take from 1 week to a few months to be fixed. Don't get discouraged if you still see that the claim is processing!