Wiki Worker's Comp Appeal Letter

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wmcodylee

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Okay, so I am fairly new in billing and coding! Can someone give me an example of an appeal letter for underpayment from workmans comp. From what I understand, if the physician is not in network work with the workmans comp, then they pay by the fee schedule of the state. I am in Louisiana.
 
Found this Louisiana Workman Comp Act Reimbursement Schedule. The part you need is Chapter 25. But I think the rest is also helpful.

Also I mostly dealt with Dissability Claims so I've only seen appeal letters in terms of that. So I wouldn't know one from WC from a hole in the ground, sorry.
 
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I am not familiar with Louisiana's regulations with regards to workers' compensation claims, but I am happy to provide you with general information. Look up the amount that should have been paid, and sent written documentation to the claims administrator, asking that it be reviewed. Double check that modifiers, CCI edits, etc. are all applied correctly before appealing to make sure that the claim submitted is correct.

I have appealed hundreds of California workers' compensation claims, and if you lay out the facts for the claims administrator in a clean, concise format with supporting documentation from the CPT manual, ICD-9 manual, or official fee schedule guidelines and asking them to review a specific line item, denial, etc., your chances of success are much higher than sending a "generic" letter requesting a review.

Good luck!
 
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