decisionhealth Newsletters, Part B News - 2018 Issue 12 (December)
Note from the instructor: How to perform a technical evaluation of denials
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Article Overview
This article is a practical overview of the early steps used to evaluate claim denials from a technical perspective. It is aimed at revenue cycle, billing, and appeals staff who need to understand how payer status, coordination of benefits, account notes, claim records, and documentation reviews factor into denial analysis and correction workflows. The piece also touches on common areas that may require follow-up by billing or coding staff and highlights the operational importance of tracking appeal effort against expected recovery.
Why This Topic Matters
A structured technical review can help identify whether a denial should be appealed, corrected, or sent for additional review. Understanding the information sources involved in the process supports more efficient denial management and better coordination between appeals, billing, and coding teams.
Article Sections
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Technical evaluation of the denial
Introduces the technical review approach for denied claims and the main sources of information used in the assessment. It also addresses payer identification, appeal handling, and documentation review within the revenue cycle.
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Payer, claim, and record review
Covers review steps involving coordination of benefits, contract status, appeal requirements, type of bill, physician orders, and the medical record. The section explains how these factors are checked during denial evaluation and correction workflows.
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Outpatient charges and coding review
Focuses on outpatient billing issues, including charge verification and follow-up review of possible diagnosis or procedure coding discrepancies. It also discusses coordination with billing and coding staff when additional corrections are needed.
What You Will Learn
- How a technical denial review is organized
- Which payer and billing records are commonly reviewed during denial analysis
- How documentation and coordination-of-benefits information support appeal preparation
- When a denial review may lead to correction and resubmission workflows
- How appeals teams coordinate with billing and coding staff
Who Should Read This
- Revenue cycle staff
- Billing staff
- Appeals team members
- Practice leadership
- Coding staff
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