Processing medical claims can get confusing, especially when someone files an appeal. According to the Department of Labor (DOL) Employee Benefits Security Administration (EBSA) there are four determinations during the medical claims process that can be appealed by anyone.
An urgent care claim is one that would substantially impact the life of the claimant or result in severe chronic pain unmanageable without treatment. Pre-service claims are those that require precertification by a healthcare provider before services are rendered. Post-service claims are those payments due after health services are rendered. Disability claims are those that create a medically related barrier to the claimant’s return to work.
All claims and appeals must be responded to as soon as reasonably possible. Administrators only have up to 30 days to respond, with the possibility of a one-time 15 day extension. Any requests for additional information or clarification must be detailed and specific.
The claimant has up to 45 days to respond. He or she is also entitled to any rules, protocols or medical basis for the determination free of charge. This exchange can make the burden of claims processing expensive and quite time consuming.
We want to take care of this headache for you, so you can focus on the care of your patients. The APEX EDI medical claim filing software simplifies the claim payment process. Our award winning team understands the laws related to claims processing, protecting health information and they want to save you time and money.
Contact APEX EDI for a demonstration of our software today!