Seven Tips To A Successful Medical Necessity Appeal

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.

1. Request Immediate Peer-to-Peer Review. See AppealTraining.com Letter Topic Medical Necessity, Subcategory URAC Standards for peer-to-peer request letter. Access these letters directly.
2. Request carrier’s medical necessity definition and any applicable published review criteria used in decision. See AppealTraining.com Letter Topic Medical Necessity, Subcategory State Medical Necessity Terms for your state’s medical necessity letter. Access these letters directly.
3. Review carrier’s compliance with utilization review standards and describe deficiencies in appeals. See AppealTraining.com Letter Topic Medical Necessity, Subcategory State Medical Necessity Terms for your state’s UR regulations letter. Access these letters directly.
4. Cite internal quality care guidelines that support treatment. See AppealTraining.com Users Forum on Contract Negotiation for information on addressing quality care guidelines in managed care contracts. Access this forum directly.
5. Cite peer-reviewed literature that supports treatment. Looking for peer-reviewed information for a specific procedure? Post your inquiry to the AppealTraining.com Users Forum to see if your colleagues have information regarding where to find supporting literature to include with appeals. Access the user forums here.
6. Submit letter of medical necessity from referring physician as well as treating physician. Point out consensus among face-to-face treating providers, if possible.
7. Pursue all levels of appeal and independent review, where available. See AppealTraining.com Letter Topic Medical Necessity, Subcategory State Medical Necessity Terms for your state’s independent review request letter. Access these letters directly.