Do you have a love-hate relationship with forms? Most insurance carriers have an appeal submission form to use when pursuing an appeal. The carrier may even have separate forms for providers versus patient appeals, appeal versus grievance issues and plan-specific or state-specific forms to collect the appropriate data for the claim in question.
Don’t let the complexity stop a valid appeal. Keep in mind that the information tracked by the appeal form is important to the outcome.
There are pros and cons of filing an appeal on a carrier form. Electronic submission, better carrier tracking and higher compliance with state and federal appeal review requirements are facilitated by standardizing incoming appeals information. Many forms require the submitter to designate what type of appeal is being submitted (medical necessity, coding, coordination of benefits, etc). This data helps carriers and regulators identify and trend areas of concern involving denials and report more precise information to industry regulators.
Another important function of the form is to clarify the authorized representative. Providers now submit many appeals on behalf of the patient. However, the appeal review requirements may vary according to whether the provider is exercising the appeal rights as outlined in a provider agreement or if the provider is representing the patient via the patient’s right to appeal. The difference may seem semantic. However, as an appeal proceeds through higher levels of appeal and even possibly to litigation, provider appeal rights tend to be more limited. Patient’s appeal rights are more broadly recognized and protected under both state and federal consumer protection laws. If the form includes a designation of authorized representative signature area, this formal recognition may give you the authority to demand disclosure of patient-specific information, such as policy language, clinical criteria and prior claim history.
The downside of carrier appeal forms is clearly the inability to squeeze a persuasive, complex, clinical argument into the confines of the three- to four- lines of text provided on the form for the appeal/grievance explanation. Most forms clearly state that additional pages can be attached to the form. In that situation, we recommend submitting the form manually with an attached standard appeal letter. This allows the submitter to fully develop the appeal and reference all supporting documentation in a format that is easier for the reviewer to follow.
Comments on your organization’s effective use of payer forms are welcome at the AppealTraining.com Discussion Forum.
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