Billing Medical Insurance: Claim Disputes & Challenges

When we ask offices why they do not bill medical insurance the reasons range from “it’s too hard” to “I don’t have time.” However, medical billing will help your patients make the most of their benefits and strengthen your practice with a new revenue stream and increased case acceptance. According to a national study, 65% of medical claims are never challenged!

Here are a few tips for billing medical insurance and insurance company policies you need to know.

Aetna  

Claim reconsideration – this takes place prior to a formal appeal.  Issues that would warrant reconsideration are not limited to:

1. Provider contract issues
2. Claim payment policies
3. Processing errors (them thinking this is for dental issues)

Things to remember:

• Reconsiderations must be filed within 180 days of initial claim submission.
• A request can be submitted online through Navinet.net.
• A request may also be submitted by phone.
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Level 1 – Claim Reconsideration

If you are following up after reconsideration and the decision is not in your favor, a level 1 appeal should be requested either in writing or verbally.

1. 1. Must be done within 60 calendar days of the reconsideration decision.
   2. Provide medical necessity or additional information for some investigational/experimental criteria.
   3. Additional information was not provided at first submission.

Per Aetna, they must respond within 30 days if no additional information is required for adjudication.  

BCBS of Texas

Level 1 – Claim Dispute

1. 1. There is a specific claim review form to fill out on their website.
   2. Forms must be submitted within 180 days of receiving the Explanation of Payment (EOP).
   3. BCBSTX will respond with written notification within 45 days.

Level 2 – Claim Dispute

1. 1. If your decision for level 1 appeal is unfavorable, the 2nd level appeal must be completed within 15 days.
   2. BCBSTX will respond within 30 days of receipt of level 2 appeal.

Cigna

Level 1 – Provider Reconsideration Request:

Step 1

1. 1. Contact Cigna representative to request reconsideration.
   2. You will be advised if the representative is unable to help and an appeal must be completed.

Step 2

Complete and mail the request for a health care professional payment review form from their website and/or appeal letter along with all supporting documentation.

Level 2  – Appeal Requests:

This must be received within 180 calendar days from the date of the initial payment or denial decision.  Appeal requests will be handled by a reviewer who was not involved in the initial decision.

1. Complete the Cigna Appeal form and submit with additional information and any prior information submitted.
2. Include a copy of the original claim.
3. Make sure to include a clinical component such as services were denied for no prior authorization, include the operative report and any other documents that support medical necessity.

United Healthcare

Level 1 – Claim Reconsideration

1. A claim reconsideration request must be submitted within 12 months from the date of the EOB.
2. Reconsideration may be submitted on www.optum.com or at www.unitedhealthcareonline.com.  Select claims and payments then claim reconsideration.

Level 2 – Claim Appeal

1. A formal level 2 appeal request must be submitted within 12 months from the date of the EOB.
2. Attach all supporting materials such as clinical records, the reason for the request or medical necessity supporting documentation (as in articles, medical doctor letter, or website information).