Unfortunately, one of the most frustrating and common denial responses from carriers are the words “Denial upheld. No new information submitted.”
A No-New-Info appeal response is a clear signal that your organization may be submitting form letter appeals without making claim-specific customizations to the appeal letter. Appeal form letters have become routine in the industry and payers can easily spot an appeal which has been auto-generated using claim data alone. An appeal should provide patient-specific information to support the appeal and the type of information to include depends on the denial.
Further, in addition to providing claim-specific details and clarifications, appeals are an opportunity to request disclosure from the payer regarding the specific policy of plan language used to make the decision. A disclosure request embedded within an appeal letter puts the payer at risk for non-compliance with certain disclosure laws regarding adverse benefit determinations. However, any appeal requesting disclosure will be most effective if it also contain a patient authorization to appeal form.
Appeals should be as customized as time and information dictates. Even if an appeal form is utilized, make sure that your appeal staff is providing additional customized information to make the appeal more precise and the argument for payment stronger.
As follows are a few common denial types and our suggestions regarding how to customize your appeal relate to this denial type:
Timely filing – Any timely filing appeal letter should be customized to cite the date of initial submission along with documentation of the original submission. For high-dollar claims, you may even want to submit an attestation of original filing date signed by medical biller who submitted the claim. Your disclosure request can ask the payer for an audit of their records to see if there was a claim backlog at that time or a loss of data which may have impacted receipt of the original claim.
Medical Necessity – Medical necessity appeals should be customized with extensive information from the patient medical record. Some of the pertinent information to summarize in the appeal include treatment history, persistent and/or exacerbation of symptoms with less aggressive treatment, clinical guidelines used to develop treatment plans and physician’s letter of medical necessity. Your disclosure request should focus on obtaining the credential of the medical review, the clinical guidance used to assess the treatment and the specific definition of medical necessity used by the payer.
Benefit Reduction/Discounting – Benefit reductions/discounting are often ambiguously applied to claims without sufficient explanation. Therefore, your appeals should provide information to support your coding such as specialty-specific coding guidelines and/or documentation from the medical record which pertains to the code selected. Your disclosure request can ask the payer to provide a review by a certified coders with a detailed response regarding how benefits were calculated and what policy/plan language allows the payer to make the adjustment.
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