The majority of the appeal letters can be used by any type of health care provider. We have many hospital and physician subscribers as well as ancillary and alternative/complementary care providers.

Yes. We have a number of different letters to refund/recoupment responses which range from challenging untimely requests to seeking more detailed disclosure related to the reason for the action.

Yes. We have a number of letters developed for prior authorization denials. Further, our medical necessity appeal letters can be very helpful if the denial is strictly clinical.

Yes. We have a number of specialty-specific letters.

Absolutely. Some of the sample letters may contain enough information to persaude the insurance carrier to reconsider. However, many types of denials, for example a medical necessity denial, will likely require some treatment-specific information to be effective. The appeal letters are meant to provide some various ideas on how to present information but are in no way exhaustive or complete. Users must use their judgement in deciding what information would be persausive on each appeal and include additional information accordingly.

One of the most important aspects of appealing denied claim is to understand the laws that apply. Many group insurance policies are governed by ERISA and are exempt from state mandates. Other payors, such as Medicare and Medicaid, fall under a different set of claim processing regulations. It is beneficial to familairize yourself with the various types of potentially applicable laws and discuss which laws apply to which payors with your attorney. The U.S. Department of Labor, State Department of Insurance and other governmental web sites also often provide some education information regarding this issue.