Medical Auditing Practice Exam

What should be included in an appeal package after reviewing erroneous denials based on NCCI guidelines?

1. Documentation of services

2. Original claim forms and EOBs

3. Clinical notes

4. Patient satisfaction surveys

The correct answer is: Original claim forms and EOBs

An appeal package designed to address erroneous denials based on the National Correct Coding Initiative (NCCI) guidelines must contain comprehensive information to support the case effectively. Including original claim forms and Explanation of Benefits (EOBs) is essential for a number of reasons. Original claim forms provide the billing details that were submitted to the insurance company, which helps to clarify what services were billed and how they were coded. These forms are crucial as they serve as the foundation of the claim and illustrate that all necessary information was initially provided. EOBs, on the other hand, detail the insurance company's findings regarding the claim, including the reasons for denial. By attaching these documents, the appeal demonstrates an understanding of the reasons why the claim was denied and provides a basis for addressing those issues. Including this information can help facilitate a clearer dialogue with the insurer about the validity of the claim. While documentation of services, clinical notes, and patient satisfaction surveys could offer valuable insights into the patient's care journey and the appropriateness of the services rendered, they do not serve as primary evidence for contesting the initial denial as effectively as the original claim forms and EOBs do. Therefore, the inclusion of original claim forms and EOBs is vital for constructing a robust appeal