When you get a denial from your payer, your first step may be to immediately start putting together an insurance appeal letter so you can capture the pay for services you’ve provided. That’s an excellent habit, as long as you know what to include in your letter.
Check out four steps that can help you write a winning appeal letter every time.
1. Evaluate Why Your Claim Was Denied
You cannot simply appeal a claim because you want the money. You must know why the claim was denied so you can explain why it should be overturned as part of your insurance appeal letter.
Appeals typically come down to two main categories:
- Denials associated with a billing edit (such as an NCCI bundle)
- A denial for clinical reasons (such as a medical necessity denial)
Once you know which one you’re dealing with, it will be easier to file your appeal. If it’s a billing edit, you can search the plan’s policies by the code, by the actual claim payment policy, or to see if there is an NCCI edit, which points back to the code to code relationship.
If it’s a clinical denial, always search the plan’s medical policy guidelines again to find proof that you submitted the correct documentation supporting medical necessity coverage guidelines and that you reported payable diagnosis and procedure codes.
2. Include Vital Encounter Information
It may seem obvious that you need to include vital information about the patient and the denied claim in your insurance appeal letter, but payers say that many practices miss this element in their haste to explain their case. Therefore, always make sure the following details are in your letter:
- The patient’s name, spelled correctly and matching what’s in the payer’s system
- The date or date range of service
- The claim number(s)
- The patient’s payer ID number
- The patient’s date of birth
3. Share the Payer’s Own Policy
The best way to support your appeal is to show the payer not only the proof that you met their policy guidelines, but also the policy itself. You can either include a copy of the policy in your appeal, or you can cite the local coverage determination (LCD) number in your letter. This way, the appeal representative will easily be able to reference the payer policy and your proof that you met the relevant sections of that policy.
Many medical practice staff members skip this step because they rationalize, “The payer should have their own policy, there’s no need for me to send it.” But the reality is that easier you can make it for the payer rep to compare your appeal against the policy, the faster they can process your appeal.
4. Explain Your Rationale in Your Own Words
You should share why you’re appealing in your insurance appeal letter to demonstrate the rationale. This can be helpful for payer representatives who don’t see the connection independently.
Example: Suppose a patient came to the emergency department (ED) after cutting her hand on an aluminum can. The ED physician gave her four stitches and recommended a tetanus shot, but the patient refused the shot. After the patient went home, her family members urged her to get the shot, so she returned to the ED later that day and got the tetanus shot. The insurer paid the first claim, but denied the one for the tetanus shot because it was billed as a separate encounter on the same date of service for the same diagnosis.
Your insurance appeal letter should have a detailed explanation of the patient’s decision to go home without getting the shot, and then returning later for it. The second visit was outside of your control, but was within the ED physician’s medical advice and you had a medically necessary reason for administering the shot.
Don’t leave your appeals to chance. Let expert Tressa Harley help you submit winning appeals during her online training, Get Your Denied Claims Paid Fast with Proven Appeal Process. Register today!
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The post Master the Perfect Insurance Appeal Letter in 4 Easy Steps appeared first on Healthcare Training Leader.