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Free Example of A Claim Essay

When claims are submitted for payment there are possibilities that they might not be always honored. At times claims are denied even after all the necessary procedure have been followed. In cases where all the necessary steps have been carried out in the appropriate but yet still the claim is denied it becomes necessary for an appeal to be made. This paper examines four common examples of reasons why claims are denied. The paper will also explain why am appeal is important.

Why a claim can be denied

Reasons for denial of a claim are many and differ with the situation at hand. Claims can be partially or totally denied. The following illustrations explain in details:

If a patient is given some treatment and then discharged, the clams for such will include the drugs which were prescribed at the local pharmacy. The medical claim however does not contain the drugs which the patient is given as a take away to be used at home. These drugs are not covered regardless of weather they are part of the medication or not a long as they are to be taken away. Therefore a claim can be denied because of including such drugs (Holmes 2008).

Another illustration is in the same field whereby there is a requirement that some specific surgeries can only be performed on in patients only. If a claim is presented for the case of a surgery carried out on an outpatient facility then a claim is entirely denied and as such no payment will be made to the claim (Dunn 2009).

Thirdly it has been reported that most of the reasons for denial of claims arise from the mistakes committed on authorization and eligibility grounds. When patients are admitted inappropriately or on the wrong authority then claims which accrue from such are prone to be denied. Lastly, incomplete physician records may cause clinical errors which may lead to a claim be denied (Holmes 2008).    


It is important that that if a claim is denied, the party involved seek an appeal. The coding and billing officers can help out in solving a denied claim. 

Code: Sample20

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