Claim Appeal

Submit a claim appeal from a provider.

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• The appeal can be used to reverse a denial for a service in a claim.

• Denials are issued to the providing contractor through an EOB (Create EOB form).

• This is a user-defined form created using RADplus Utilities modeling functionality.

1. In the Select Client screen enter the client's name, click Select Client Name. Select the client, click Ok.

2. In the Appeal received date field, enter the date the appeal were received.

3. In the Appeal Type field, select Initial or Secondary.

4. In the Denial Type field, select all denial types that initiated the denial of the service, as stated in the EOB.

5. The Member Name field displays the member's name, and select.

6. In the Contract field, enter the funding source name, and select.

7. In the Benefit Plan field, enter the plan name, and select.

8. In the Provider field, enter the provider name, and select.

9. In the Claim Number field, enter the claim number associated with the denied service.

10. In the Authorization Number field, enter the authorization number associated with the denied service. in order to view the information contained in all Service Authorizations associated with the member.

11. In the Dates of services and services provided field, enter the dates for the services that are being appealed.

12. In the Reason claim should be reconsidered, enter the reason.

13. In the Supporting clinical documentation, enter supporting documentation information.

14. When finished, click Submit.