Method and system for managing appeals

A non-transitory computer readable medium comprising computer executable code for managing insurance claim denials for a plurality of healthcare providers, the computer executable code comprising instructions for:

• comparing a claim denial of a healthcare provider to a denial status grid comprising a list of denial types and an appeal success rate for each denial type on the list by a review module of a processor-based server, wherein the review module provides a recommendation to proceed with or to decline to proceed with an appeal of the claim denial based on the comparison and a patient record associated with the claim denial;
• determining to proceed with the appeal of the claim denial based on the recommendation;
• preparing an appeals package comprising an appeals overturn letter and a supporting document in support of the appeal to the claim denial by the review module of the server;
• electronically submitting the appeals package to an insurer associated with the claim denial by an appeals coordinating module of the server over a communications network to file the appeal to the claim denial;
• monitoring the progress of the appeal filed with the insurer by a process management module of the server;
• processing an appeal determination electronically received from the insurer;
• and
• determining by an appeals decision matrix module of the server to file a second level appeal when the appeal is denied or partially denied.

A web-based computer system for managing insurance claim denials over a communications network, comprising:

• a hardware server for managing claim denials for a plurality of healthcare providers and comprising:
• a review module for comparing a claim denial of a healthcare provider to a denial status grid comprising a list of denial types and an appeal success rate for each denial type on the list, providing a recommendation to proceed with or to decline with an appeal of the claim denial based on the comparison and a patient record associated with the claim denial, wherein a determination to proceed with the appeal of the claim denial is based on the recommendation, preparing an appeals package comprising an appeals overturn letter and a supporting document in support of the appeal to the claim denial;
• an appeals coordinating module for electronically submitting the appeals package to an insurer associated with the claim denial over the communications network to file the appeal of the claim denial;
• a process management module for monitoring the progress of the appeal filed with the insurer;
• and
• an appeal decision matrix module for processing appeal determination electronically received from the insurer and determining whether to file a second level appeal when the appeal is denied or partially denied;
• a database for storing the claim denial, the patient medical record, the appeals package and the appeal determination;
• and
• a plurality of processor-based devices to access the server over the communications network, each client device associated with a health care provider.