Most denials require two appeals for two reasons: first, insurance carriers do not always provide credentialed professionals for the initial review and second, insurance carriers often provide details in the Level I appeal response which may require further discussion. Level I appeal responses should be scrutinized for legal and contractual compliance. Some of the potential questions you should ask include:
- Has the insurer provided the internal rules, guidelines or review criteria applicable to the denial? If not, is the carrier in compliance with potentially applicable denial disclosure laws?
- If provided, does the internal rules, guidelines or review criteria cited by the insurance carrier actually apply to the treatment in question? Do the internal rules, guidelines or review criteria conflict with your internal quality care standards?
- Has the insurer provided review by a credentialed professional familiar with the type of treatment?
- If the appeal involves a question of medical coding, has the insurer provided review by licensed coder familiar with the type of treatment?
- If the appeal involves a managed care contract or fee schedule, is the most current contract or fee schedule being utilized?
A Level II appeal should address all details regarding the justification for payment and should also address the shortcoming or inapplicability of the information cited in the carrier’s Level I appeal response. Finally, citing applicable regulatory information in appeal letters assures you that the appeal will also be considered from a compliance standpoint.
AppealTraining.com has a number of letters citing state and federal disclosure laws which assist medical providers with demanding more complete information regarding denials. These letters are under the Topic: Benefit Reductions and the Subcategory: State Mandates in the AppealTraining.com Appeal Letter Repository and include a number of new state-specific disclosure letters.
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