Creating Appeals Require Training

October 15, 2021

To ensure that your medical practice is successful, you need to understand that you have the right to a full and fair appeal review and you need to hold payers accountable for decisions that impact patient care – and your revenue. However, writing a medical insurance appeal in order to dispute a rejected claim can be quite challenging, especially when considering new payer medical necessity and coding guidelines. Simply writing an effective appeal can take a lot of time and effort. The following are some of the basic tips to keep in mind when creating an effective medical insurance appeal.


Before Beginning the Appeal

The very first thing you should do is to determine the reason the claim was rejected. In some cases, the benefits verification process has ruled out denials based on eligibility, which means there’s no need for a letter. In some cases the claim that was rejected is so small that the process of going through an appeal may not be worth the time and effort. However, once you determine that it is worth the effort to write a medical insurance appeal, there are a number of things that have to be included.

How to Write the Appeal

The basis of your medical insurance appeal should be an argument against the reason why the claim was rejected. Unfortunately, this can be more difficult to figure out than you might think. More often than not, the rejected claim only includes a small statement on why the claim was denied without explaining the motivation behind the actual denial. Besides carefully reading through the claim rejection, look up the CAGC (claim adjustment group code), CARC (Claim adjustment reason code) and RARC (remittance advice remark code) for additional information regarding the denial. Once you’ve identified the reason behind the rejection, there are three types of medical insurance appeals that you can write:

1. Coding Appeal – You’ll need extensive knowledge of coding to create a letter that provides documentation that supports the diagnosis-related group billed. This usually requires you to research coding rules, coding updates and possibly even request letters of clarification from physicians to file as late entries into the medical record.

2. Medical Necessity Appeal – This type of appeal requires you to go into detail about who the patient is, their medical history, their condition when they came, their symptoms and how they were treated. You’ll need to reference the standards of care, focus on physician intent and reference the Medicare Benefits Policy Manual if possible.

3. Administrative Appeal – An administrative appeal may be required if you have a weak clinical argument. In this appeal, you’ll have to focus on the your intent to admit the patient as an inpatient. You’ll need to argue that the services you provided were consistent with how Medicare defines inpatient admission. You’ll need to reference the Medicare Benefit Policy Manual to write an effective administrative appeal.

When writing any of these types of appeals, make sure to include:

As you can see, there’s a lot involved when it comes to crafting a medical insurance appeal. Considering how complicated all of this is and how much time it takes up, you may want to think about seeking assistance in writing your medical insurance appeals from our team at ProMD.

ProMD Practice Management is happy to help with your billing assessment needs so you can maximize profits and increase patient satisfaction. To learn more about how ProMD can make your practice run like a well-oiled machine, call 888-622-7498 or fill out our online form to request a billing assessment.

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