Method and system for managing appeals
OwnerOlakunle Olaniyaninventor
Life of this patent
Estimating the term…
Abstract
A system and method for managing insurance claim denials. The system and method reviews a denial of claim from an insurer and a patient medical record received from a healthcare provider to determine if an appeal should be filed for the denial. It prepares an appeal to the denial comprising an appeals overturn letter and supporting document and submits the appeal to the insurer if it determines that an appeal should be filed. The system then tracks and monitors the progress of the appeal and process the appeal determination received from the insurer. The system utilizes these tracking and monitoring information to streamline and improve the insurance claim process of the healthcare provider, such as developing and implementing claim denial reduction program.
Claims42
A method for managing insurance claim denials, comprising the steps of:
- reviewing a denial of claim from an insurer and a patient medical record received from a healthcare provider to determine if an appeal should be filed for said denial;
- preparing an appeal to said denial comprising an appeals overturn letter and supporting document;
- submitting said appeal to said insurer;
- monitoring the progress of said appeal;
- and
- processing appeal determination received from said insurer.
A computer system for managing insurance claim denials, comprising:
- a nurse review module for reviewing a denial of claim from an insurer and a patient medical record received from a healthcare provider to determine if an appeal should be filed for said denial, and preparing an appeal to said denial comprising an appeals overturn letter and supporting document;
- an appeals coordinating module for submitting said appeal to said insurer;
- a managed cared organization (MCO) process management module for monitoring the progress of said appeal;
- and
- an appeal decision matrix module for processing appeal determination received from said insurer.
The computer system of claim 116, wherein said MCO process management module is operable to alert an operator or representative to contact said insurer.
A computer readable medium comprising code for managing insurance claim denials, said code comprising instructions for:
- reviewing a denial of claim from an insurer and a patient medical record received from a healthcare provider to determine if an appeal should be filed for said denial;
- preparing an appeal to said denial comprising an appeals overturn letter and supporting document;
- submitting said appeal to said insurer;
- monitoring the progress of said appeal;
- and
- processing appeal determination received from said insurer.
Dependencies are inferred from the claim text.