The following is a list of steps to preparing an appeal:
- Address the appeal letter to the Insurance Company who paid/rejected the claim.
- If this is your 2nd Level Appeal or 3rd Level Appeal, notate that on the header also. If it is your first there is no need to be specific.
- Put the Date that you are preparing the appeal on the appeal letter.
- Address the appeal to: To Whom It May Concern.
- Include the Patient Name, DOB, ID#, DOS and Billed Amount of the claim originally submitted.
- Point out the reason for claim denial. Example: This claim was denied for timely filing however according to our records this is incorrect.
- Provide an explanation as to why this is incorrect based off of: Contract, Fee Schedule, Timely Filling Submission Dates, Coding Guidelines, State Rules & Regulations (resources for Texas: TID, TMB, TMA, TCMS), Federal Rules & Regulations (CMS, AMA, HIPAA, OIG, HHS, FDCPA, PHI, Prompt Pay Act), Payor Guidelines, Provider Information or Credentials that rendered the services, Medical Necessity, Patient Benefits, Authorization on file, Any other applicable reason for an invalid denial
- Close with expectations: Please reprocess for payment according to our contract, Please reprocess according to our fee schedule, Please see attached proof of submission for timely filing, Please reprocess per coding guidelines (list the exact coding guideline), Please reprocess according to rules & regulations (list the exact rule or regulation that they violated), Please correct the CPT Code/ICD9 Code, Please reprocess with attached information regarding medical necessity, Please make additional payment within 14 business days
- Attach any applicable documents: Contract (if necessary), Fee Schedule (if necessary), Proof of Timely Filing, Documentation on Coding Guidelines, Documentation on any State and/or Federal Rules & Regulations, CPT, HCPCS or ICD9 Code information, Copy of Provider information (Provider License, Provider Credentials, Practice Information, etc), Medical Records, Copy of Patient Benefits, Copy of Authorization, Or any other further documentation to support the denial
Utilize these 9 steps and you will have the foundation for an effective Appeal Letter to win the fight against the insurance carrier! We wish you great success! If we can assist you further, please to not hesitate to contact us at 817.239.6595
[The steps are written for Providers in the State of Texas…some of the resources listed may not apply to your state.]