Appeal Drafting Guidelines

Appeal

What is an appeal?

An appeal is the action one can take if one disagrees with a coverage or payment decision made by
insurance.
One has the right to appeal on a claim that is initially submitted with incorrect information containing
data-entry error like wrong date of service or on inappropriately paid or denied claims such as late
filing, prior authorization and vice versa for review and reprocessing.
Appeal drafting guidelines

Here are the guidelines, one should follow for appeal drafting;

Identify and understand why the claim was denied:

Before appealing a denied claim, first find out if claim needs to be appealed. See denial reason(s) on
explanation of benefits (EOB) or electronic remittance advice (ERA) to determine if this can be
appealed. If one still isn’t sure why the claim was denied, contact insurance company and ask the
reason of denial. Once it has been determined that it is appropriate to file an appeal then further
adopt the method of appeal as some denials may be requested for review based on a telephone
conversation through reopening lines. Otherwise file a written appeal following the appeal filing
guidelines accompanying supporting documentation in order for the claim to be reconsidered for
reprocessing.
Appeal drafting guidelines
Write to the insurance company, following their guidelines:
An effective appeal is more than a letter demanding payment; it is an argument supported by
evidence. Examine the insurance company’s reasoning for denial. Make a list of the reason(s) that
one disagrees with the insurance’s decision. It is important to use appropriate appeal forms according
to State and insurance as some insurance plans require to use their own forms for appeals. Begin
appeal letter from salutation, further give the reference; patient, date of service and the claim number
in concern. Following this introduction, describe the service for which payment was denied. Keep the
focus on writing the reason for review and possible reimbursements.

Incorporate evidence with right paperwork:

An effective appeal goes beyond opinion. To dispute a denial based on the necessity of a service or
the need to have provided it as a distinct service it should be accompanied by supportive references,
published reimbursement policies by an insurance, referrals, prescriptions from the doctor and any
relevant information such as medical history that may help the claim get approved the second time
around.
Appeal drafting guidelines
Appeal correspondence/submission:
It is important to file/submit the appeal to right corresponding address. Mostly payers have a
designated address (physical and postal) for sending appeals. This information may be included on
the patient’s insurance card, one can also communicate with the insurance to obtain the
correspondence details.
If you do not hear back from an insurance in a reasonable time, confirm the status of initial appeal
first before appealing on same claim.

Follow up with the insurance company:

Once you submit an appeal, it’s important to follow up in 30 days by calling the insurance as some
insurance companies will allow claims to suffer for months if no one follows up. Keep calling at
regular intervals if you do not hear back from the insurance company. If they haven’t received
appeal, get the fax number so you can fax the appeal, once faxed, confirm that the fax was received.
Appeal drafting guidelines
Stay organized by maintaining the logs
Document all the details of your conversations with insurance. Take notes during every phone call
with the insurance company such as name and the job title of the person you spoke and write down
the date of the conversation, also ask for “call reference number”, and if an appeal was submitted, get
the “document control number”. This information will help to quickly access all the necessary
information for follow up call with insurance.

Appeal Forms:
Most of the payers accept the online appeals submitted through their web portal. One can check
online if the respective payer accepts online appeals.
One can also obtain appeal forms from web portal.
One can also call at help line of the payer to find out appeal process.