How to Write an Effective Appeal Letter Lisa Scott, CPC, COSC, CBCS

Why Appeal? If you believe the insurance payer did not process a claim correctly, then appeal the adjudication decision Non-payment of services Underpayment for services Bundled services Justification Proof of insurance verification Contracted fee schedule Clinical guidelines Billing and coding guidelines

What is Included in an Appeal Letter? A letter from the doctor addressing the specific issue to be resolved Any pertinent information from your medical records Any professional journal articles that will substantiate your claim Copies from CPT, ICD, HCPCS, and/or professional coding journals to substantiate your coding decisions

Include Identification of the Claim Patient’s name Subscriber’s name Claim number (assigned by the payer) Policy and group name and number Provider’s name Practice name NPI, EIN numbers DOS

Include the Reason for Denial Use the reason for denial as explained by the payer Per a denial letter Per the EOB/ERA EOB/ERA Review their edit codes and remarks Make sure you understand what they mean and how they apply If you do not understand the reason for denial, call the payer!

Include Clinical Details Brief history of the illness or circumstances surrounding the service provided Medical necessity of selected treatment Quote from medical records as needed Office notes Operative reports Attach copies of records if needed Highlight what you want the payer to read

Include the Correct Information Procedural codes Diagnostic codes Modifiers Preauthorization/preapproval numbers Allowable amount Benefits applied incorrectly

State Why You Believe their Decision was Wrong It’s a battle of wits You have to prove you are right Provide specific information based on FACTS to show that treatment should be provided, was provided correctly, was coded correctly, etc.

Tell the Insurance Payer What you Expect Them to Do Reprocess the claim Under the correct benefit level Under the correct preauth number Under the correct fee schedule Pay, or pay an additional amount How much you expect to get paid How much additional money you expect to get paid Timeframe When you expect to receive a response Generally 45-60 days

Give Them Contact Information Your name Your email address Your direct phone number In case they have questions…… Or need additional information……..

Closing Statement Thank you for your prompt consideration of this matter…….. I look forward to your timely response……. Should you need clarification or additional information……. BE NICE!

Sample Appeal Letter See your handout