Filing an Appeal or Reconsideration

Understanding a denial from an insurance company is an important step in knowing how to file an appeal or reconsideration. First, re-check the claim and make sure all diagnostic and procedure codes were entered correctly, as well as the place of service. If the explanation code on the explanation of benefits (EOB) does not make sense, call the insurance company and ask for a more detailed explanation. While on the phone, ask how to file an appeal. Timely filing of an appeal is essential, as some companies only allow 120 days from the date of the EOB.

Health insurance companies use elaborate computer systems that automatically compare diagnostic codes with services rendered and additionally match those with the place of service. If the system does not find an approved diagnosis, for example, for radiation therapy, that procedure will be denied as ‘not medically necessary.’ This is not the final word on the matter, however, and an appeal will be reviewed by a staff medical specialist. There are exceptions to almost every rule and a computer can never replace a trained medical professional, who looks at all aspects of the medical care rendered.

Different insurance companies will ask for several items. Most insurance companies will have the appeal process stated on their website, along with downloadable or printable forms. Follow the instructions exactly to ensure the appeal will be considered the first time it is submitted.

The following are some of the documents requested by most insurance company appeals departments:

Copy of HCFA 1500 claim that was denied

Copy of the insurance company EOB showing the denial

Letter from physician referencing patient name, member number, claim number, date of service, billed amount, procedure code denied, and the doctor’s explanation of why the claim should be reconsidered.

Copies of medical notes, records, test results, etc.

Copies of coding guidelines from Medicare (if it is a coding dispute)

Filing an Appeal or Reconsideration

Several insurance companies also require a Waiver of Liability (United Healthcare example) to be completed and signed by the physician, plus require that their own form be filled out in lieu of a letter from the physician. The correct address to send all the documents to is a critical piece of information, as it may be different from the address where claims are normally sent.

Mailing several appeals in one envelope is not recommended. Each appeal should be separately packaged and mailed with a return receipt guaranteeing delivery. Following up with the return receipt is inexpensive and provides extra insurance that your appeal is delivered. It is very disheartening to follow all of the above steps and make a follow-up call to the insurance company in a few weeks, only to be told that they have not received the appeal. Several insurance companies will allow appeals to be faxed to them. Always call after faxing to ensure all the pages of the appeal were received.

Following up on an appeal is helpful because if any further documentation or explanation is required for further review, a phone call will expedite this information faster than a letter from the insurance appeal department. Appeals can take anywhere from 21 days to 90 days; flagging the calendar to make follow-up inquiries is a helpful reminder, or creating a ‘To Do’ in your medical claims billing software.