Appealing vs Submitting a New Claim

Knowing when to appeal and when to resubmit a rejected claim can mean the difference between receiving just payment and inadvertently committing insurance fraud. The very first step is knowing what type of rejection you are dealing with and understanding whether it’s a technical or merit-based rejection.

If you receive a rejection notice requiring more information and the claim is not denied, this is known as a technical rejection. Usually this will require information to be sent concerning the patient information from boxes 1 through 13 and boxes 25 through 33 on the CMS 1500 form (f.k.a. HCFA 1500). In this case, it is okay to resubmit the claim with the correct information.

On the other hand, if your claim is denied due to information from Box 14 through box 21 on the CMS 1500 form, then NEVER RESUBMIT, APPEAL INSTEAD! This is known as a denial based on the merit of the claim. Typically you will be denied based on lack of medical necessity or bundling of service.

In short, if the claim is rejected due to missing information, then you may resubmit the claim. If rejected due the merit of the case, then appeal the decision.

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