Appeal review deadlines vary from plan to plan and payer to payer. However, there are appeal deadlines applicable to most claims.
A 60-day appeal response deadline is common among many types of plans. The Medicare Appeals Process applicable to Fee for Service claims requires that First Level Appeals, Redeterminations, be decided either by a letter, Medicare Summary Notice (MSN) or remittance advice (RA) within 60 days of receipt of the redetermination request.
Among private payers, many follow claim processing accreditation standards set by the Utilization Review Accreditation Commission (URAC). The claim processing standards established by URAC require accredited plans to process appeals within 60 days. URAC.org maintains a searchable list of insurance companies who are accredited under the claims processing standard and also has a complaint review process for reviewing complaints related to non-compliance.
State laws related to appeal review are occasionally established requiring even prompter appeal response and may also require the organization to acknowledge receipt of the appeal. For example, California’s managed care grievance procedure laws require an appeal decision within 30 and require acknowledgment of receipt of a grievance within five days.
The American Medical Association tracks health fines issued by state regulatory agencies and the California Department of Managed Care has fined a number of health care payers for failure to promptly acknowledge and process appeals. A chart of fines issued by various state agencies is at http://www.ama-assn.org/resources/doc/psa/insurer-fines.pdf. The chart demonstrates that state enforcement of prompt payment laws is growing. However, California stands out in its efforts to enforce the appeal review standards.
AppealTraining.com has a number of appeal letters to assist providers with seeking compliance with prompt appeal review requirement. The following letters cites the URAC Claim Processing Standard requirement that accredited organizations review appeals within 60 days. You can check an organization’s accreditation status at http://urac.org or file a compliant at http://webapps.urac.org/complaint/.
Dear Appeals Department,
Our office recently filed an appeal related to the above referenced claim. However, no response was received from your company. It is our position that this failure to promptly respond to the appeal is a violation of the Utilization Review Accreditation Commission (URAC) Claim Processing Standards.
As you are likely aware, URAC claim processing standards require organizations seeking to maintain claim processing accreditation to establish a claims appeals process and process appeals within 60 calendar days. Further, a health professional must be involved in any adverse determination that involves clinical judgment.
Please accept this written request for an immediate appeal response. We also request the name and credentials of the health professional involved with the review as well as a copy of any policy language, clinical criteria or other resource used in the review and specific instructions for initiating the next level of appeal.
Sincerely,
Leave A Response