Get Attached To Appeal Attachments

Yes, your appeal letter may be highly persuasive. You may feel victory is at hand! However, pause one moment before sending the appeal letter and consider the fact that almost every appeal letter can be improved with a related attachment.

Attachments are often the “proof” that the insurance reviewer needs in order to overturn a denial. Also, attachments can affect the review costs and time burden on the insurance carrier. Your attachment, not the appeal letter content, may be the driving factor in whether the appeal is processed internally or submitted to an outside consultant with expertise in the area in question. Medical records are the most common appeal letter attachment. A summary of the clinical justification for treatment should appear within the body of the letter but is typically not sufficient documentation for the insurance carrier. The medical records’ history and physical is also a good source of information on what other providers might have pertinent information regarding past treatment and the patient’s treatment resistance. This information may also be highlighted and a recommendation included in the appeal letters to obtain this additional information before rendering an adverse determination.

As follows are five other potential attachments which can make the winning difference in your appeal efforts:

Internal Clinical Criteria For Treatment Plan Development – Many medical providers utilize published clinical criteria for treatment plan development. For example, many hospitals utilize Interqual for assessing length of stay and level of care. Physicians may utilize a specialty specific source for guidance on treatment plan development. These published industry standards should be submitted with your medical necessity and prior authorization appeals to demonstrate that recognized quality care is being sought for the patient.

Fee Schedule Information – Incorrect in-network payments must be challenged with written documentation of the agreed upon reimbursement. Most states have managed care protections that require managed care organizations to disclosure the fee schedule upon contract finalization or upon request by participating providers. Further, states may impose additional restrictions on modifying the fee schedule without prior notification. Therefore, it is important to obtain the fee schedule and keep track of any modifications and their implementation dates. For codes that are individually negotiated by your organization, written documentation must be disseminated to the billing and appeal staff so that this documentation can be easily attached to appeals.

Prior Authorization Letter – Don’t forget the obvious! Submission of any prior authorization related to a denied claim can be very compelling. Many states regulate the terms that allow an insurance carrier to rescind or refuse to honor an assignment of benefits. Therefore, it should be presented with the appeal and any refusal to honor the authorization should be reviewed for compliance with state regulations as well as the plan or policy language.

Specialty Coding Published Standards – Carriers employ a number of claim coding edits that are often not fully explained at the time of the denial. Coding appeals can focus on seeking the specific coding standard used by the carrier in making the decision. However, coding appeals are even stronger if the billing professional submits specialty specific published coding standards that support full payment.

Managed Care Contract Provisions – Managed care contracts often include terms which have a direct bearing on claim payment, benefit calculation, medical necessity review and appeal review. Cite any applicable wording and include the contract for greater strength. Providers should attempt to negotiate prompt payment time-frames, clean claim definition, notification requirements and medical necessity terms which protect healthcare quality. These contractual obligations will play an even greater role under Accountable Care Organization and pay per performance models.

For a more complete list of potential appeal attachments, visit the Download Library. We identify 19 categories of attachments which can make appeal letters more persuasive.

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