A remittance pays zero with a remark that the patient’s maximum benefits for the service category have been met. What should staff do before filing an appeal?
Select an answer to reveal the explanation.
Short Explanation
“Max benefits met” might be right—or the accumulator might be wrong. Peek at the benefits and year-to-date totals before you fire off an appeal. If the well really is dry, appealing on principle wastes everyone’s time; if the count is off, then appeal with proof.
Full Explanation
Benefit-maximum denials should be validated against current eligibility and accumulator information before appeal. If the plan correctly exhausted benefits, appeal is unlikely to succeed and posting should reflect the determination per contract. Appeals are appropriate when accumulator data or plan application appears erroneous. Balance-billing beyond allowed amounts or changing codes merely to evade benefit limits is improper.