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

2. 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

3. 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

4. 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

5. 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!

6. 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

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

8. 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.

9. 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 days

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

11. 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!

12. Sample Appeal Letter
See your handout