Appeal Process

• A claim requires an appeal when it has been processed and denied by the payer and the issue cannot be corrected by simply resubmitting or correcting the claim.

• The appeals process typically consists of two stages:

            1 - Reconsideration (first-level appeal)
            2 - Appeal (second-level appeal)

• A second-level appeal should be submitted if the reconsideration (first-level appeal) is upheld.

• There are 3 modes for submitting an appeal: fax, mail or portal. It is important to confirm the accepted submission modes with the insurance representative and you should give priority to fax and portal modes if it is acceptable as it takes less time to receive by payer.

• When submitting an appeal for any denial, it is necessary to prepare a package that includes at least two documents.

            1 - General Letter or Insurance-Specific Appeal Letter

            2 - Supporting Documents

• General Letter or Insurance-Specific Appeal Letter:

• Many insurance companies have specific appeal letters that must be completed and submitted when filing an appeal. The first-level and second-level appeal letters may differ, so it is important to contact the insurance representative to confirm the requirements for both reconsideration and appeal letters. Sometimes, these information are also available on their portal.

• An appeal letter generally includes the following sections:

• Patient Information
• Provider Information
• Insurance & Claim Information
• Reason for Submitting Appeal

• If the insurance company does not provide a specific appeal letter or form, you will need to create a general appeal letter that includes all of the above information.

• Below is the example of general appeal letter. You may modify the wording as needed or get client approval before using it.

• Supporting Documents: These should include all supporting documents that strengthen your appeal. They will be reviewed by the insurance company and may help overturn the original decision.

• Below are the denials and the corresponding supporting documents that can be attached when submitting an appeal.

• TFL Denial: It requires POTF (Proof of Timely Filing) to be submitted. POTF can be any documents that prove the submission of claim within the timely filing limit of the insurance. The documents must include submission date and below documents can be used as POTF.

• Clearinghouse Submission Report
• Payer Acknowledgement / Acceptance Report
• EDI Acceptance Screenshot

• Medical Records Required or Insufficient Document Denial: This denial requires submission of the documents that can support the denial CPT.