Appealing Claims
Many claim denials or underpayments are the result of errors on the claim form, such as:
- Incorrect or inappropriate codes (CPT*, HCPCS)
- Missing or incorrect numbers of units
- Incorrect or transposed patient information (eg, insurance identification number, date of birth)
- Incorrect modifiers
These claims must be corrected and resubmitted for appropriate payment. Resubmitted claims should be clearly marked "resubmission" so that the payer will not consider it a duplicate claim for the same services.
At times, a payer may request additional documentation to support proper claims processing. This request for additional documentation does not indicate that the claim has been denied; however, the claim cannot be processed further and is considered pended until the healthcare provider has responded to the request for further documentation.
Some claims are denied simply because of payer processing errors, such as:
- Inappropriately applied discounts when a contract between the payer and provider does not exist
- Delays in downloading current codes into claims processing systems
- Incorrect application of coverage and benefit limitations on a patient's policy
If a payer denies your claim for payment or the claim was not processed appropriately, you may file an appeal. Filing an appeal not only assists in resolving a dispute regarding the specific claim, but also notifies the payer that they may need to address issues within their claims editing software and processing systems.
Depending on the claim issue, a phone call to the payer's claims department requesting that the claim be reprocessed may be sufficient. However, payers often require a formal letter of appeal. Healthcare providers should customize an appeal letter to provide as much relevant patient-specific information as possible and, where applicable, demonstrate why the therapy is medically necessary for the patient. Providers may wish to identify an individual within the practice or facility who will be responsible for gathering all of the necessary information for the appeal and monitoring the appeal as it is processed.
Steps for success in managing an appeal for a denied claim:
- Review the claim thoroughly to identify the reason for the inaccuracy or denial
- Gather supporting documentation to support your appeal
- If you have not previously submitted a detailed letter of medical necessity, it may be advisable to include one in the appeal packet
- If you have already submitted a letter of medical necessity, you should include a letter of appeal indicating why the medication should be covered and reimbursed by the payer
- The following items may also be appropriate for inclusion in an appeal packet:
- Copy of the original claim
- Copy of the denial notification from the payer
- Patient's complete medical history and clinical notes
- Relevant peer-reviewed articles supporting use of the medication
- Designated payer-specific appeal form (when required)
- Submit the appeal within appropriate timeframes. Many payers require that appeals be submitted in 30 to 60 days from the date that the claim was originally denied. If the appeal is denied, additional appeal levels such as review of the claim by the payer's medical director may be available
- Maintain a log to follow up on denied and inappropriately paid claims
*Current Procedural Terminology (CPT), Professional Edition, 2009. American Medical Association, 2008. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no responsibility for the data contained herein. CPT is a registered trademark of the American Medical Association.
