5 Video Lessons

Medical Necessity

Medical necessity appeals shape healthcare. Uncontested medical necessity denials result in a subtle shift in treatment availability to the next patient because insurance carriers aim to consistently apply medical necessity limitations. Effective medical necessity appeals, on the other hand, bring to the carrier’s attention necessary variations in care, emerging efficacy issues, and situations that reveal flaws in the day-to-day clinical application of the carrier’s written criteria. For this reason, quality appeal review is critical to each of us. Appeal Solutions has detailed tools for improving medical necessity appeals.

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Lesson 1: An Ill-Defined Term

Lesson 1: An Ill-Defined Term

Medical necessity is a term which has different meaning to different health care participants. Understanding the carrier’s definition is hel...
Lesson 2: Medical Necessity Appeal Component 1: Summarize the Patient’s Care

Lesson 2: Medical Necessity Appeal Component 1: Summarize the Patient’s Care

The cornerstone of your appeal will be developing a compelling clinical argument for the care and referencing published clinical care guidel...
Lesson 3: Medical Necessity Appeal Component 2: Cite Regulatory and/or Compliance Information

Lesson 3: Medical Necessity Appeal Component 2: Cite Regulatory and/or Compliance Information

Clinical arguments are often not sufficient to overturn an adverse determination. Your appeal must also cite potentially applicable regulato...
Lesson 4: Medical Necessity Appeal Component 3: Demand Disclosure of Payer’s Denial Basis

Lesson 4: Medical Necessity Appeal Component 3: Demand Disclosure of Payer’s Denial Basis

Payers rarely fulfill the obligation to fully disclose the basis of medical necessity denials. Reviewer's credentials, clinical review crite...
Lesson 5: Pursue All Levels Of Appeal

Lesson 5: Pursue All Levels Of Appeal

Persistence is essential to success in medical necessity appeals. The highest quality review occurs at the highest level of appeal but you c...

Course Materials:

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Course Instructor

Tammy Tipton

President of Appeal Solutions, Tammy Tipton is an author and frequent speaker and expert on resolving denied and disputed medical insurance claims.

Course Objectives

What You'll Learn:

  • An Ill-Defined Term
  • What Goes Wrong With Medical Necessity Review
  • Medical Necessity Appeal Component 1: Summarize the Patient’s Care
  • Medical Necessity Appeal Component 2: Cite Regulatory and/or Compliance Information
  • Medical Necessity Appeal Component 3: Demand Disclosure of Payer’s Denial Basis

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