Managing Denied Claims in firstREV
For the most part, users manage claims in the same manner using firstREV, but if a claim is denied then users must be able to properly review the denied claim so they can know how to proceed, so that reimbursement can be received. When a claim is denied, it has been processed by the payer and deemed unpayable. This is usually due to services that do not meet the proper criteria for coverage or eligibility. Specific reasons can vary from a range of possibilities, but may include MCD denials, LCD denials, ICD-10 diagnosis codes, CPT or HCPCS procedure code edits, complex medical reviews of claims involving progress corrective action cases, etc.
When the denied claim is returned to the firstREV interface, the payer includes an explanation of why the claim was denied.
Viewing a Denied Claim
Just like the process for opening other claims, click on the desired record in the Institutional Claims or Professional Claims grid to open the claim. Users can filter the claims grid so denied claims are the only records shown in the grid. Open the Profiler menu, check the corresponding box to enable the Denied filtering option, and then click Apply. While viewing the denied claim, a notification will display at the bottom of the claim form: “This claim has been denied by the payer. View remittance for more information.”
Users can access remittance associated with denied claims by clicking the Related tab to the far right. From within the Related tab, click the “Remittance” link to open the corresponding remittance file.
Viewing Denials from the Remittance Screen
Users can also view remittances associated with denied claims while viewing the Remittance (Claims) grid. From the toolbar, click Collections and then select Remit Detail to access this screen. Just as performed while viewing the claims grid, users can filter the remittance grid so denied remits are the only records shown in the grid. Open the Profiler menu, check the corresponding box to enable the Denied filter (in the Remit Status section), and then click Apply.
Click on the corresponding record to view the denied remit (or click 
in the Action column). After opening the remittance document, users can review the same remit details (i.e. Payer, Provider, Patient, Claim Payment, Services, Supplemental Information, Notes) as if accessed from the Related tab while viewing the denied claim. Additionally, the original claim can be accessed while viewing the remittance by clicking the Related tab and then clicking the corresponding link for the claim you want to view. This is simply a convenience that provides users with multiple ways to obtain the information they need.