Appeals Should Clarify Fuzzy Denials: Claims Often Fall in Claims Adjudication Grey Area

Some appeals succeed, others fail. Why? Unfortunately, many appeal letters fail because of THE CLAIMS ADJUDICATION GREY AREA.

Health insurance policy language is notoriously unclear. Verification/Preauthorization requirements can be ambiguous. Payment methodology is inconsistent and contradictory. Medical Necessity is perhaps the most difficult term to clearly define. Even appeal procedures are often ambiguous and appeal responses fail to address issues raised in the appeal and disclose pertinent policy information.

Appeal Solutions wants to help you improve the success rate of those appeals by 100 percent. We cannot guarantee a 100 percent increased reimbursement on your organization’s denied claims. We can, unquestionably, assist you achieve a higher reimbursement rate and clearer, more detailed, responses from insurance carriers. How? By providing appeal letters which cite state and consumer claim processing protections which force the carrier to clarify the Claims Adjudication Grey Area.

If the denial is related to preauthorization, our letters make a strong demand for release of preauthorization requirements as outlined in the patient’s policy or plan document. Our utilization review appeal letters assist with demands regarding how the carrier is accredited and if the utilization review process meets accreditation standards.

If the denial is related to payment methodology, our letters demand that the carrier release the formula used to calculate benefits as well as the source and publication date of any outside pricing data.

If the denial is related to medical necessity, our letters are useful in demanding the medical necessity definition and clinical criteria used in the decision-making. These are the appeal demands that lead to successful resolution.

What do you do with this information? Analyze the denial details for language or ambiguities which support your claim. If the information does not clearly support the denial or underpayment, your next level of appeal can cite the carrier’s own information or lack thereof and how it can be interpreted to imply coverage for the services in question.

This process is time consuming but effective and educational. Getting your hands on the details behind the decisions is critical to successful healthcare appeals. The more you know, the more you win at appealing denied claims.