In a perfect world all submitted claims would be processed and paid, on the first submission. But anyone in the billing world knows that is not how it works. Many claims are processed and paid on the first submission, but some are not. The ones that are not need to be dealt with. Some just need to have a minor correction and resubmitted, but some need to be appealed.
What does it take to successfully appeal a claim?
- Have a process in place – knowing how to file an appeal and having a process in place for the most commonly filed appeals is key. It will save time and frustration. When a process is already in place, it makes preparing and filing the appeal much easier.
- File the appeal as quickly as possible – most insurances have a time limit on when appeals can be filed. The quicker the appeal is filed, the better. If for any reason the appeal was not received, it can be resubmitted if there is enough time. If the appeal is filed quickly, it allows for these types of issues.
- Identify the reason for the appeal – make sure that the appeal is noted as an appeal and that the reason for the appeal is clearly stated on the first page of the appeal. If the insurance carrier has a specific form, use that form and make sure to check the appropriate reason for appeal. If no form is available attach a letter or cover sheet identifying that the claim is being appealed and why.
- Attach any/all documentation to support the appeal – the more documentation supporting the appeal, the more likely to receive a favorable response. For example, on a timely filing appeal, attach any clearinghouse reports, practice management reports, and/or USPS reports showing when the claim was submitted. Also attach a letter explaining any delays. When submitting an appeal because the doctor disagrees with a service/procedure being denied for medical necessity, attach all medical records, a statement from the doctor explaining his/her argument, and any medical documentation supporting the service/procedure for the diagnosis.
- Note the patient’s file – make sure to document when the appeal was filed and how it was filed. It is also a good idea to keep a copy of the appeal (electronically) so that it can be referenced if needed.
- Follow up – If a response to the appeal is not received in a timely manner, follow up with the insurance carrier to find out the status of the appeal. Sometimes insurance carriers will state that they did not receive an appeal. If a follow up is done, the appeal can be resubmitted. Don’t just sit back and wait for a response. Most insurance carriers respond to appeals within 30 days.
Many providers do not appeal denied claims. This can cause them to lose a lot of revenue. Appeals do not have to be complicated. Once a system is in place it doesn’t take that much effort. Follow the six steps above and stop your practice/provider from losing revenue that they are entitled to.