DecisionHealth, DecisionHealth - 2018 Issue 12 (December)

Note from the instructor: How to perform a technical evaluation of denials

A denial represents the health care insurance company’s decision not to adjudicate the claim because of a conflict over service, payment or coverage. Starting from this perspective, the appeal strategy must begin with identifying the payer. Next, determine whether the health care insurance is classified and managed as a commercial or government payer and whether the provider’s organization is a contracted or non-contracted entity.

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