Claim Denial Management: How to Correctly Appeal and Fight Denials

Claim Denial Management: How to Correctly Appeal and Fight Denials

Tips to take the pain out of appealing denied medical claims

Denials can be overwhelming, here are some tips to help know if you need to appeal and the process to get it done effectively.

Understand the denial

Verify the information initially provided on the claim, and ask yourself the following questions.

  • Does the documentation justify the CPT and ICD codes billed?
  • Were the modifiers appropriate or missing?
  • Are the TOS (type of service) and POS (place of service) codes correct?
  • Was this bundled with another procedure, either in the post op period or the same day?
  • Did you verify that you are following LCDs, NDC or medical policy guidelines for the payer

Understand the process

Levels of appeal summary

Level 1:    120 days after date of initial date of determination

Level 2:    within 180 days of the date of the Redetermination decision.

Level 3:    within 60 days of the reconsideration decision

Level 4:    within 60 days of the ALJ’s decision

Level 5:    within 60 days of the DAB decision

Gather supporting documentation

What to include:

  • Notes for procedure as well as other supporting documentation (past treatment notes showing what has been tried and failed)
  • Referral or authorization from payer
  • Original claim number assigned by payer
  • Proof of timely filing, if necessary

What is NOT needed:

  • New claim form
  • Copy of insurance card
  • Documentation that has already been submitted for review
  • Copy of denial

Write a strong appeal letter

  1. Be direct and intentional with your first sentence.
  2. Clear description of issue and expected outcome
  3. Give supporting information about coding, coverage expectations pertinent to that payer.
  4. Quote coverage policy and give policy # in letter.
  5. If you are appealing a “unlisted” procedure (ex 64999), give comparable procedure and the rate you expect it to be paid.
  6. Don’t overdo it. Be clear but not too “wordy”.
  7. Include some medical backing for why you think this should be paid-for example “The patient had 90% relief with diagnostic MBB”.

Melissa Billman

About the author: Melissa Billman is the billing director for C E Medical Group, a nation-wide medical billing firm that specializes in working with pain management, sport medicine, family practice, and orthopedic surgery. In addition to managing her large team of medical billers and coders, she speaks nationally at various billing and coding conferences. Melissa resides in Salt Lake City, Utah with her husband and two children.