What to Expect in a Denial Appeal Process with Health Insurers

By: Pearl Walia When do Payer Disputes Result in an Appeal?  According to the Change Healthcare 2020 Denials Index, about 50% of denied claims result from front-end issues, including eligibility or prior authorization problems, service coverage disputes, questions of medical necessity, inadequate documentation, or untimely filing. In simple terms, the payer refuses to pay the claim at all for one of these reasons.1  However, appeals don’t arise from outright denials; they can also result from an underpayment or overpayment. An underpayment occurs when the payer pays less than the contracted amount for the service provided, often due to downcoded CPT/HCPCS…

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