Healthcare appeal letter development can involve extensive pre-submission ground work.
Often, the necessary information for appeal letter development must be gathered from a number of sources including the patient and other medical providers. Detailed clinical appeals may require a review of medical literature. Even technical appeals may require information gathering from various organizational departments or off-site personnel.
The National Association of Insurance Commission has recommended that that consumers have broad time frames for filing appeals. NAIC specifically recommended that healthcare reform address this issue by requiring carriers to provide at least six months for appeal filing.
However, many providers are reporting carrier use of more strict appeal filing time frames.
For example, we were recently contacted regarding a carrier’s refusal to process an appeal because it was submitted past 45 days. The provider was not sure whether to cite the state appeal filing deadline of 60 days or the ERISA appeal deadline of 180 days. In many scenarios, a provider contract may also apply. Further, a quick internet search revealed that the carrier had online information referencing a 60 day appeal deadline.
Why not call the carrier to clarify the appeal filing deadline? Can you trust information received from the carrier customer service line regarding appeal filing?
According to many healthcare treatment advocates, the answer is “No.”
“It is our view that, to the extent possible, communication from issurers/plans should be in writing. We say this based on the cumulative years of experience some of us have had, which informs us that information provided by customer service representative by telephone too often is erroneous,” states a letter submitted by a group of organizations commenting on strengthening the external review requirements of the Affordable Care Act.
The letter goes on to describe how one of the organizations received erroneous appeal address via carrier customer service. The appeal was refiled but, again, the carrier indicated that the appeal was not received and that, in fact, the appeal address being used was incorrect.
“The third time was, indeed, a charm, and the appeal was successful. However, it took constant vigilance and three mailings of a fairly substantial appeal. Because the appeal was filed long before the deadline for filing, and there was proof of mailing, the subsequent mailings were not late. However, the consumer had to wait approximately ninety days for a decision due solely to repeatedly getting bad, very basic information over the telephone.” Source: American Cancer Society Network Cancer Action Network website (See ACS CAN Joins Comments To Strengthen Regulation on External Appeals at www.acscan.org/mediacenter/filter/from/2011-07.)
When obtaining appeal filing instructions by phone, be sure to request written appeal instructions as confirmation. Further, you may want to cite the ERISA claims procedure regulation when appealing claims involving a group health plan governed by ERISA.
Paragraph 3 of Title 29 of the Code of Federal Regulations, Section 2650.503-1, “Claims Procedure,” outlines the following appeal requirements involved in a full and fair review of an adverse determination:
Group health plans. The claims procedures of a group health plan will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless, in addition to complying with the requirements of paragraphs (h)(2)(ii) through (iv) of this section, the claims procedures–
(i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination. . .
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