How are medical claims handled in the event of rejection or denial from the payer?
This article applies to clients subscribed to Outcomes’ Clinical Documentation or Medical Billing services.
Outcomes Medical Billing Process
In the event that a medical claim is denied or rejected by the payer, our Outcomes Medical Billing team will review the claim to determine the next steps. This includes:
- Claim Review and Correction:
If a denied claim can be corrected, and the correction is appropriate based on billing and compliance standards, our Medical Billing team will submit the corrected claim to the payer on the pharmacy’s behalf. - Claim Appeal Process:
In cases where the claim is denied and requires an appeal, the Medical Billing team will assess if the claim is appealable. If so, our team will submit the appeal directly to the payer. - Additional Information Requests:
If further information is required to correct or appeal the claim, our Medical Billing team may reach out to your pharmacy for the necessary details.
Pharmacy Action Required
No action is required from your pharmacy unless you are contacted by our Medical Billing team for additional information.
Questions
If you have any questions or would like to discuss pricing, please contact our Outcomes Customer Service team.