Wiki medically necessary-APPEALS

[Revenuecycle]

Any tips on appealing when the denial states not medically necessary? One denial is bc the payer says that the "service can be safely received in a setting other than a hospital inpatient room".????

 

[dclark7]

I would suggest that you get the provider involved in these types of appeals. (S)He knows their reasoning for what they do and should be able to explain it. I've found that most providers don't have the time or inclination to write appeals, so what I would usually do is request a meeting with them, let them know why the claim was denied and go over their thought processes. Then I would write the letter give it to them for review/correction and send it out with all supporting documentation. sometimes there are reasons that are not readily apparent and like I tell my docs "your thoughts don't photcopy."