A patient's claim for a complex surgical procedure was denied by their insurance company. The denial stated that the procedure was 'not medically necessary'. Upon review, you discover that the patient's records clearly document the medical necessity of the procedure. What is the most appropriate next step to address this claim denial?
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Resubmit the same claim with an attached note stating the procedure was medically necessary.
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Immediately direct the patient to pay for the procedure out-of-pocket since the insurance denied the claim.
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Adjust the patient's bill to exclude the surgical procedure and proceed with collecting the remaining balance.
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File an appeal with detailed supporting documentation and a letter from the physician explaining the medical necessity of the procedure.
The correct action to take when faced with a denial due to a dispute over medical necessity is to file an appeal and include supporting documentation, such as medical records, that demonstrate the procedure's necessity. It’s essential for the appeal to be accompanied by a thorough explanation and any relevant evidence that substantiates the claim. Merely resubmitting the claim or providing insufficient documentation will not address the denial effectively and could delay the resolution.
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