Are the appeal letters designed for hospitals, physicians or other specific type of healthcare providers?
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.
An insurance carrier is asking for money back that we believe was correctly paid. Do you have anything for refund/recoupment issues?
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.
We are primarily interested in challenging prior authorization denials. Can the letter be used for this purpose?
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.
Do you have specialty-specific appeal letters?
Yes. We have a number of specialty-specific letters.
Can I make changes to an appeal in the appeal letter database before I send it?
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.
Some of the letters cite legal information. How do I know if the legal information is applicable to the claim I am appealing?
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.