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3rd Party External Review Process

E

Evargas6357

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6
Location
Adkins, TX
Can someone give me some insight on the external review process. My doctor wants me to request an external review from Maximus (Texas). I have exhausted the appeals/reconsideration process with the insurance and now he wants a third party external review submitted. Researched the process but this is something I have never done before and not sure I understand it. The claim was denied for 2 codes bundling to each other, doctor states modifier 59 was appropriate as separate incision sights.
 
I'm guessing this is not workers comp, because the situation is different for that. So, if it is commercial insurance:

It looks pretty straightforward from their webpage: https://www.tdi.texas.gov/consumer/external-review-process.html

I did this in California, for a surgery for my son, because my insurance wouldn't authorize it. It was fast and easy, and I believe it was also Maximus.

Oh yeah, and we won.

You only get one shot, so make sure you attach any documentation showing why it should be paid, photographs, billing and coding guidelines (copy the pages from the book), etc. Keep your appeal letter brief and direct. Quote the reason for the denial in your letter, then refute the reason.
 
SharonCollachi said:
I'm guessing this is not workers comp, because the situation is different for that. So, if it is commercial insurance:

It looks pretty straightforward from their webpage: https://www.tdi.texas.gov/consumer/external-review-process.html

I did this in California, for a surgery for my son, because my insurance wouldn't authorize it. It was fast and easy, and I believe it was also Maximus.

Oh yeah, and we won.

You only get one shot, so make sure you attach any documentation showing why it should be paid, photographs, billing and coding guidelines (copy the pages from the book), etc. Keep your appeal letter brief and direct. Quote the reason for the denial in your letter, then refute the reason.
Click to expand...
Thanks for your help, will definitely ensure all documentation is in order before submitting.
 
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