How to Proactively Address Denials

Want to improve the Payment Error Rate for the next round of review? Be sure to learn about and understand claim denials before the end of round education with the Case Management Team. Start working proactively.

The most important step: Make sure your team is using NGSConnex. It’s a free, secure, web-based application developed by National Government Services just for you. NGSConnex provides access to many self-service functions that save you time and money.

With the help of NGSConnex, you can monitor for claim review decisions, find denial narratives and address trending issues right away.

First, ensure the appropriate individuals have access to NGSConnex. We suggest having multiple people with NGSConnex access to ensure consistent access and monitoring.

1. Monitor NGSConnex for incoming ADRs. Responding timely prevents nonresponse (692) denials.
2. Submit documentation for clinical review through NGSConnex in response to ADRs.
3. Monitor NGSConnex for claim decisions.
4. When a denial is identified, find the denial narrative. The denial narrative is located in the ADR Details view in NGSConnex, in the Additional Review Information field. The Additional Review Information field is visible in the lower right corner of the ADR Details view, as seen on the screenshot below. Click on the link in the field to see the denial narrative that contains additional details about the denial from the clinical reviewer.

Once the denial narratives have been located and reviewed, create an internal plan to address the denial reason(s). This proactive approach can prevent subsequent denials of the same category by addressing issues within the round of TPE review, thus reducing your Payment Error Rate and potentially preventing the next rounds of TPE review. A few proactive steps can make a massive difference in the outcome of your TPE review.

The denial rationales can also be found on page 04 of the FISS DDE Provider Online Guide.

Reviewed 6/20/2024