Appeals – Status and Appeal tab

APPEAL 

Understanding Appeals

An appeal is a process where a patient or provider attempts to persuade an insurance company to cover healthcare costs that were initially denied. Medical billing specialists handle appeals following claim denials or rejections by insurers.

Key Points to Remember:

1. Natera’s appeal process is a courtesy provided to patients.
2. No guarantee of success: An appeal doesn’t ensure insurance coverage.
3. Patient responsibility: Patients remain liable for charges and will continue receiving notices.
4. We don’t proactively offer appeals: Only initiate if requested.
5. Appeal timeline: If applicable, the process typically takes 45 to 60 business days from the creation date.
6. Communication options: Upon request, we can send appeal information to the insurance company via fax or email.
7. Appeal date verification:
   • Generally, the appeal initiation date is the ‘Created Date’ in the STATUS tab.
   • If information is available in the APPEAL tab, this may contain the correct appeal date.
8. Patient Responsibility Appeals: We cannot appeal Patient Responsibility charges (PR1, PR2, PR3) on behalf of the patient. In these cases, patients must contact their insurance directly.

WHAT TO SAY?

When there’s ONE appeal denied but patient wants us to send an appeal again:

AMD / CUSTOM TAB / STATUS 

Details of denied claims will only be visible in this tab; if there are no rows under STATUS, there is no denial.

A bill does not necessarily indicate an insurance denial; it might be a partial payment due to pending amounts based on the out-of-pocket maximum. Check the Reason Codes in the History tab for clarification.

To identify the test related to a denial, refer to the VISIT #, as this tab does not display case numbers.

Note that not all denials can be appealed. For those that can, the CREATED DATE on the right side of the screen indicates when the appeal was sent.

 

Here’s an explanation of the important fields represented in the STATUS tab: 

• Make sure you understand how to proceed before telling patients if there’s an appeal or not. 
• It takes 30 to 45 business days for a claim to be answered. 

DOS: This is another way to find out when was the date of sample collection  

VISIT NO: Use it to identify individually each test as this tab won’t show the corresponding case number  

STATUS: Claim’s response. 

The status may not give you full details, so always check the FU STATUS to better understand.  

Those highlighted are the most frequent scenarios and the ones that you should be paying attention to 

• PAID Insurance paid for the claim 
• DENIED Insurance denied the initial claim 
• NOT RECEIVED Insurance states they haven’t received a claim from Natera yet 
• IN PROCESS Insurance hasn’t finished answering the claim 
• CIP RESPONSE RECEIVED Patient has a Controlled Insurance Program plan, and the insurance is still working on the claims’ answer  
• PATIENT RESPONSIBILITY Insurance will establish the amount patients need to pay as there’s a pending amount to be covered, such as deductible, coinsurance or copayment 
• REFUND Insurance overpaid for the claim and needs a refund 
• PENDING CREDENTIALING Provider’s credentialing is still pending 
• PAYOR HOLDS Any reason that might stop the insurance from completing a claim 

 FU STATUS: Action taken with the claim.  

Always check on the SECONDARY STATUS to get a better understanding.  

Those highlighted are the most frequent scenarios and the ones that you should be paying attention to 

 

• AWAITING EOB Insurance is still in the process of sending the EOB to the patient 
• PATIENT BILLED Insurance determined patient has a responsibility to pay for 
• CHECK RE ISSUED REQUESTED If a check hasn’t been cashed within a specific timeframe, Natera may need to request for it to be reissued 
• CIP Patient has a Controlled Insurance Program plan 
• PAID AND POSTED CLOSED Insurance already paid and there were no other complains from Natera and/or patient 
• PENDING RESOLUTION Insurance hasn’t posted their final decision for the claim 
• REBILLED E, F or P There is incorrect information on the claim, and the insurance requires for it to be reissued  
• REPROCESSED Initial claim was voided and new claim was submitted 
• SECONDARY BILLED Patient has a secondary insurance and Natera is sending a claim to the second company 
• VCARD PAYMENT Insurance made their payment to Natera with a Virtual Credit Card 
• WRITE OFF Insurance might have written off the patient responsibility 
• APPEALED This is the most common one. For some SECONDARY STATUS it may mean an appeal is already in progress but even though you see an appealed FU status ALWAYS make sure you check on the secondary status to know if it’s appealable or not 
• RECONSIDERATION A request to review a claim that Natera feels was incorrectly denied or paid because of processing errors 
• RECORD SUBMISSION Natera has sent Medical Records 

 SECONDARY STATUS: Reason why the claim was denied. This is what will make you determine if an appeal is appropriate or not. 

• BUNDLING Natera sent CPT codes bundled instead of individually or the insurance is requesting to bundle CPT codes that Natera sent individually. This reason CAN BE APPEALED. Send a regular Appeal Escalation with the correct codes to be billed. 45-60 business days 

• PRIMARY EOB No primary insurance EOB information has been submitted for the secondary insurance to complete claim. This reason CAN BE APPEALED BUT normally is used with a rebilled FU status and therefore doesn’t need to be appealed but if necessary, advise patient to contact the primary insurance company so that the EOB can be sent. 

• NON-COVERED CHARGES Services are not covered due to patient’s current benefit plan. This Reason CANNOT BE APPEALED. Attempt to take payment positioning the NCS bill as a benefit Natera is giving the patient to take advantage of the discounted price. Only if the patient insists an Appeal Escalation may be sent. 45-60 business days. If appealed, it’s important to remind patients to disregard bills received while the appeal is in process and let them know that if the appeal is denied, the bill amount will be at its full cash price by then!

• MAXIMUM BENEFITS REACHED The plan works on an annual basis and procedures and procedures can be repeated only a limited amount of time within that period. This reason CAN BE APPEALED by requesting documentation to support medical need. Send a regular Appeal Escalation. 45-60 business days. If appealed, it’s important to remind patients to disregard bills received while the appeal is in process and let them know that if the appeal is denied, the bill amount will be at its full cash price by then!  

• PRV OUT OF NETWORK The provider, meaning the doctor, clinic or hospital is out of network with the insurance. Natera might be INN but not the provider. This reason CANNOT BE APPEALED. Attempt to take payment positioning the NCS bill as a benefit Natera is giving the patient to take advantage of the discounted price.

• DUPLICATE Meaning that more than one claim was submitted for the same service. There’s NO NEED TO APPEAL because in most instances, the claim was already processed.

• INVALID PROCEDURE CODE CPT codes are important part of claims and this reason refers to missing or incorrect CPT codes. This reason CAN BE APPEALED. Send a regular Appeal Escalation with the correct codes to be billed. 45-60 business days.

• COORDINATION OF BENEFITS This reason refers to the order claims for multiple insurance should be submitted. For example, if the patient has a commercial plan AND Medicaid, then the first claim should be sent to the commercial and then to Medicaid. The denial will be caused by assigning the incorrect coverage to the plan. This reason CANNOT BE APPEALED, rather you need to modify on the Insurance tab the correct coverage for each plan and complete an Insurance Update process. 30-45 business days 

• TIMELY FILING EXPIRED Insurance companies usually allow 180 calendar days from DOS for claims to be submitted; if submitted after then, the claim will be denied. This reason CANNOT BE APPEALED and it is probable that since those 180 days have passed no other plan will be willing to cover the claim.
  ANY insurance that denies for timely filing due to a Natera delay is to be written off, send a Supervisor Escalation through SyncroCRM to have the balance removed (Ensure the patient had active insurance coverage at the DOS)

• PRIOR AUTHORIZATION Patients are required to send the Prior Authorization already filled out BEFORE taking the test so the insurance can review if the plan will cover the service. If the document is not sent on time, then some insurance companies will be denying the claim and this reason CANNOT BE APPEALED. Remember it’s NOT Natera’s responsibility to get the Prior Authorization rather, we can cooperate gathering the document AFTER the patient has taken the test but we cannot guarantee the insurance will accept it. Attempt to take payment positioning the NCS bill as a benefit Natera is giving the patient to take advantage of the discounted price.

• EXPERIMENTAL/INVESTIGATIONAL Insurance companies may consider some of our tests as innovative treatments that are still under the experimental or investigational stage and the medical necessity of the test is not proven yet. We ALWAYS want to attempt to take a payment for the NCS amount, positioning the price as a benefit but if the patient insists, we MAY APPEAL ONLY IF THE PATIENT INSISTS by sending a regular Appeal Escalation. 45-60 business days. If appealed, it’s important to remind patients to disregard bills received while the appeal is in process and let them know that if the appeal is denied, the bill amount will be at its full cash price by then!

• MEDICAL RECORDS REQUIRED The insurance requests to receive the patient’s medical records which are also an important part of the claim. This reason CAN BE APPEALED. Please send a Medical Records Escalation; if the insurance is calling, make sure you capture the email, address or FAX they want us to send the medical records to and to whom should it be addressed. If the patient is calling, attempt to gather where we should send them but if they don’t know, advise that the insurance should call us. The request for the records takes approximately 7-10 business days, PLUS the appeal time, which is 45 to 60 business days. REMEMBER MEDICAL RECORDS CANNOT BE SENT TO THE PATIENT!!!

• POLICY TERMED OR INVALID If the insurance policy is already expired or there are no records of such policy number, then the insurance will use this reason to deny the claim. It CANNOT BE APPEALED, rather verify with the patient that we have the correct insurance details on the Insurance Tab; if necessary, proceed with an Insurance Update which takes 30-45 business days approximately. If there’s nothing to be modified, attempt to take payment, positioning the NCS bill as a benefit Natera gives the patient to take advantage of the discounted price. If the patient insists, have them call their insurance company for further details. 

• OTHERS Reason used to describe other denial reasons that are not listed. Please make sure you read the comments box to gather more details so you can identify why the claim was denied and if necessary, check the History tab and Reason Codes. 

• MEDICAL NECESSITY The insurance company denied because they don’t consider the service as medically necessary. The reason CAN BE APPEALED because it’s probable a specific diagnosis or modifier code is necessary or maybe a letter supporting the medical necessity. Send a regular Appeal Escalation with details of what’s needed to appeal (letter, change of DX codes, etc). 45-60 business days 

• NON-COVERED OR INVALID DX CODE This means the ICD10 code which is the diagnosis code is either not covered by the plan or it’s incorrect. This CAN BE APPEALED BUT THE CLINIC IS THE ONLY ONE WHO CAN MAKE CHANGES. Therefore, if you happen to have the patient or insurance on the line, ask them to have the clinic or doctor email us back at [email protected] so the DX code can be added or modified.  

 

COMMENTS: Additional claim details such as the claim #, date when it was answered and when the Secondary Status is OTHERS you will be able to find the reason here. Make sure you read the details in the comments box regardless of the secondary status to identify which insurance is answering and any other relevant that may be helpful.

 

 

 

Last update by: Claudia F (August 19, 2024)