The Real Deal About Appeals, Part 1

By Nancy Clark, CPC, CPC-I

Even though it seems at times that claims processing is as easy as “pushing a button”, many claims are denied. How do you resubmit your claims with the best chance of success?

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Carefully examine the denied claim for potential errors. Verify there are no mistakes in the original submission. You can save time if the error is identified and accurately revised by submitting a corrected claim instead of going through the entire appeals process.

If no errors are found, proceed to the appeals process. Understand why the claim is being denied. The denial code may be linked to an ambiguous message, such as “this service is not covered.” You may have to call the insurance carrier.

Prepare your list of inquiries in advance:

  • Clarify the reason for the denial. For example, is the service not covered because it is deemed medically unnecessary? Is this procedure specifically excluded from the patient’s benefits contract? Did the insurance carrier not recognize a modifier or modifiers on the claim?
  • When the cause of denial has been clearly identified, ask what documentation you need to appeal the claim. For example, they may request operative notes and pathology reports.
  • Confirm the insurance carrier’s formal appeal process. This may require using a form provided by the company or it may require a written appeal on the practice’s letterhead. Some commercial carriers and Medicare Administrative Contractors (MACs) have a standardized form available on their websites, while some carriers may prefer the use of a form from the state’s department of banking and insurance.
  • Obtain the specific address to which the claim should be mailed. Include the name of the department or person to whose attention it should be addressed. If possible, get a fax number. This may yield faster results.
  • Document the phone call, the representative’s name, and the date of the conversation. Keep this information in the appeal file.

Next month, we will look at strategies for writing an appeal letter that works.


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