It is possible to define the health insurance claim (appeal) as the document, which is presented to the healthcare provider and developed for the payment for services seeking. The definition of the “appeal” notion relies to the asking for the reconsideration in the case if the payment denial takes its place. There are the following two types of appeals: one, which covers the reduced payment or non-payment on the healthcare services, and such one, which may be applied as the request for the eligibility status changing for the set of the healthcare services.
There are the following cases when the claim may be denied, but the option of its appealing exists: incorrect information about the patient; terminated coverage; prior precertification or authorization is required; existence of non-covered service; benefits coordination (Jones day, 2010).
The process of appealing may be outlined in the following manner. When the claim denial is appealed in accordance with the FSA FEDS guidelines, the set of the next steps should be involved. First of all, there is a need of the initial appeal, which, in turn, may be submitted with the help of the following means of communication: postal mail, fax or e-mail. In the case if the result of the fist appeal does not satisfy the initial intensions, there is an option of issuing the first level written appeal. It should include the copies of the pertinent documents (explanation of benefits or the letter from doctor etc) (Andrews, 2011)
Also, it is possible to utilise the second level written appeal and as the drastic measures, the third party independent review may be requested. The core essence of the appeal is protecting own rights and getting the high quality and prompt healthcare services, which are implied and covered by the particular type of the insurance.
References
Andrews, Michelle (2011) Insurance claim denied? Appeal, appeal, appeal. Retrieved from: http://www.msnbc.msn.com/id/43500575/ns/health-health_care/t/insurance-c laim-denied-appeal-appeal-appeal/#.ULYDEkTKROI
Jones day official web site (2010) The More Things Change, the More They Stay the Same: Is It Worth Maintaining Grandfathered Status Under the New Health Care Law? Retrieved from: …