Wiki Need Help-Provider appeal letters

[Clmd1982]

Good Morning!

I am trying to write an appeal letter for my office to an insurance company. Trying to appeal their descision of a non-par status. We have patients that want service but don't want to pay OOP when they have coverage. I am new to this and don't know what facts and information that should be included in this letter.

I called the insurance co and they just said to write a letter and send it to this address; attention to this person.

Looking for any help, suggestions, ideas, anything. Please.

Thank you! Have a great day!!

 

[btadlock1]

Good Morning!

I am trying to write an appeal letter for my office to an insurance company. Trying to appeal their descision of a non-par status. We have patients that want service but don't want to pay OOP when they have coverage. I am new to this and don't know what facts and information that should be included in this letter.

I called the insurance co and they just said to write a letter and send it to this address; attention to this person.

Looking for any help, suggestions, ideas, anything. Please.

Thank you! Have a great day!!

The only way to appeal non-par status is if there are no other participating providers within a reasonable geographic area - otherwise the insurer sees it as, the patient had a choice to see an in network provider, yet chose to go OON instead. There are some situations, like if the patient was visiting from out of town and is out of their home area, when you can appeal OON benefits, but it's rare. You may be stuck billing the patient on this one. Hope that helps.

 

[Clmd1982]

Thats a bummer. Thanks for the imput.

 

[btadlock1]

No problem...sorry I couldn't give you a better option. I've tried to appeal these before to no avail, even when there weren't other par providers in the same state. If the patient has an in-network PCP, you can try to see if they would give you a referral (sometimes that helps), but I wouldn't hold my breath...