One of the most common denials in behavioral healthcare is a medical necessity denial. These denials occur in almost every case of substance use treatment. Carriers use medical based criteria to decide if a client's care can be authorized. If a client doesn't meet specified criteria, claims will be denied for lack of medical necessity.
Some denials are not the fault of the provider or submitting entity. Carriers often deny claims "in error" simply to delay payment.
Unfortunately, not all billers complete their work in a timely and ethical manner. Plans typically provide time frames in which claims must be submitted. If these time frames are not met, appeals have to be filed.
When A Claim Is Denied
If a claim is denied, the provider or client has the opportunity to appeal the decision. These appeals take time to process, but can be won if the correct procedures are followed.
At AVA we differentiate ourselves from other billing companies by relentlessly pursuing payment on denials and appeals until our clients receive what they are due.