Denials Management Clause Samples

Denials Management. Denials Management involves contacting payers via web, telephone, fax, and direct mail inquiries in an effort to obtain denial status information and to update athenaNet with the same. The claims processed in this workflow have been processed and denied by payers. The goal of the workflow is to identify any opportunity to initiate reprocessing or reconsideration of the claim to have the denial overturned and payment issued. In the case of a final denial, the goal is to obtain as much detail about the reasons for the denial as possible to appropriately categorize the payer and to use such information to avoid future denials. Athena places claims in this workflow in a worklist daily, for processing by the ▇▇▇▇▇ Systems Claim Tracking team. Prior to contacting the payer for claim status, claims must first be thoroughly reviewed through a detailed analysis of the claim history, including without limitation (i) review of all events visible from the claim edit page in chronological order to understand the processing to date of each claim, (ii) review of any payments posted or documentation attached to the claim which could impact the dialogue with the payer once contact is established, and (iii) review of all relevant demographic data prior Confidential Materials omitted and filed separately with the Securities and Exchange Commission. Asterisks denote omissions. to contacting the payer so that the call agent has a firm understanding of the types of insurance coverage the patient currently has or may have had in the past. On completion of the above analysis, including identification of the payer with which the claim has denied, the agent will contact the payer by calling the number(s) listed in athenaNet on the payer setup page, or by another contact method as directed by Athena. The Denials Management team will follow documented workflows supplied by Athena. Whenever possible, reconsideration should be initiated over the phone. Team members must exercise any available opportunity to initiate action over the phone or a follow-up faxed resubmission, which may quickly re-start activity on the claim and to obtain payment. Details of the call and the relevant data points collected for each payer contact event will be updated in athenaNet through (i) direct entry in unique data fields and (ii) creation of an updated claim note, which contains a unique kick code to characterize the information received from the payer and to identify the specific reason for the call.