Claims Denial Management: Take the Pain Out of Appeals

Claims Denial Management: Take the Pain Out of Appeals – By: Stephanie Thomas, CANPC

Tips to take the pain out of appealing denied medical claims
Denials can be overwhelming, here are some tips to help know if you need to appeal and the process to get it done effectively.

Tip #1: Understand the denial
Verify the information initially provided on the claim, and ask yourself…

• Does the documentation justify the CPT and ICD codes billed?
• Were the modifiers appropriate or missing?
• Are the TOS (type of service) and POS (place of service) codes correct?
• Was this bundled with another procedure, either in the post op period or the same day?
• Did you verify that you are following LCDs, NDC or medical policy guidelines for the payer?

Truly understanding your denial will guide you to your next step!

Tip #2: Gather Supporting Documentation
What to include:
• Notes for procedure as well as other supporting documentation (past treatment notes showing what has been tried and failed)
• Referral or authorization from payer
• Original claim number assigned by payer
• Proof of timely filing, if necessary

What is NOT needed:
• New claim form
• Copy of insurance card
• Documentation that has already been submitted for review
• Copy of denial

Level 1: 120 days after date of initial date of determination
Level 2: within 180 days of the date of the Redetermination decision.
Level 3: within 60 days of the reconsideration decision
Level 4: within 60 days of the ALJ’s decision
Level 5: within 60 days of the DAB decision

1. Be direct and intentional with your first sentence.
2. Clear description of issue and expected outcome
3. Give supporting information about coding, coverage expectations pertinent to that payer.
4. Quote coverage policy and give policy # in letter.
5. If you are appealing an “unlisted” procedure (ex 64999), give comparable procedure and the rate you expect it to be paid.
6. Don’t overdo it. Be clear but not too “wordy”.
7. Include some medical backing for why you think this should be paid-for example “The patient had 90% relief with diagnostic MBB”.