Medical Billing Forum
Starting a Medical Billing Business => Starting Your Own Medical Billing Business => : williamportor July 15, 2016, 08:43:36 AM
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Can someone give me some information on how to do an appeal of an insurance claim. I know this sounds pretty basic, but I've submitted over 3,500 claims in the last 2+ years, and have never had to do one. I'll have some larger contracts very soon, and I'll need to be better prepared for this. :)
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It will depend on the carrier. Some have specific forms that they require that you use. If they do, complete the form, and then attach a copy of the claim, the eob (if there is one) and any and all information that you have to support your reason for requesting the appeal. Make sure to include absolutely everything that you can to support your side. Don't assume they know anything. If they don't have a specific form, type up a short letter explaining that you are appealing the claim and give all identifying information as well as the reason for the appeal.
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It also depends on the kind of appeal. There are appeals where you may need to provide only additional information for a level one appeal and then wait and submit more for a level II appeal. There are all different appeals. Most medical billers don't understand much when it comes to ERISA appeals either.
Having worked as a claims specialist I would often receive an appeal without the additional information needed and therefore it would deny again and many physicians offices just expected to know what it was they needed to submit for their appeal. It could be as easy as a letter, or as hard as an operative report.
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I don't have to do many appeals, but when I do, if the insurance company doesn't already have an appeal form available, I have one I made myself, that I keep in my documents, and pull up and fill in accordingly. I also always send in a copy of the treatment note for the date of service, and any medical policies/LCD/NCD's for the insurance that supports why the claim should be paid. Also, if it is a specific item/service that is being denied as non-covered, be sure to have proof that the patient's policy does indeed cover that item or service, and send that in.
The last two appeals I had to do were for UHC, where they denied claims for custom molded foot orthotics, stating it wasn't a covered service under the patient's policy. But I had previously printed out the pages of each patient's benefits that clearly said orthotics were a covered service. So when I did my appeals, I sent those pages in also, and UHC immediately paid the denied claims.
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If you have a group health plan that is ERISA you don't have to use the carriers appeal forms at all. ERISA goes by federal law which is pretty uniform. When any of my clients have a patient come in with a group health plan that is ERISA, we ask them to bring in a copy of their SPB so we have it on file just in case. We also have them sign an ARF so that if we do need to appeal something we can w/out having to wait for the patient to authorize it.
The only time I bother with appeal forms from the carrier is if the plan is govt/state/church (Non ERISA) All ERISA EOB's will have Appeal information on them as well.
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Thank You everyone.