Technical denials present a unique challenge for hospitals. In these cases, the payer does not question whether the services were medically necessary, but still withholds payment on the grounds that the hospital failed to comply with procedural requirements. These may include obtaining prior authorization for outpatient services, notifying the payer and sending concurrent clinical reviews for inpatient admissions, and complying with claim submission requirements such as timely filing and coordination and benefits.
Hospital appeals teams, already overwhelmed by dealing with medical necessity denials, may not have the bandwidth to respond to technical denials; indeed, they may not even be aware that these denials are appealable. Fortunately, HLS has extensive experience in getting technical denials overturned. We investigate the relevant regulations and contractual agreements and find evidence of extenuating circumstances that prevented the hospital from fulfilling the technical requirements. By arguing that the technical denial should not foreclose a review on the merits, we are able to have technical denials reconsidered as medical necessity denials and get the services to be approved and paid on the basis of medical necessity.