None of the initial claim denials are irreversible. If your claim gets denied or underpaid, there is always an option to overturn the original decision. Healthcare providers who believe that the payment for their services has been denied incorrectly may initiate a reconsideration process with the payer. In some cases, contacting a plan’s customer service and asking them to work on the issue is enough. At the same time, there are many denials that require sophisticated arguments to have a claim reprocessed. Such arguments can be listed in a provider appeal.
What is a provider appeal? How is it different from a regular reconsideration request?
Initiating a simple reconsideration request is the first step you need to take to reprocess your denial. Such a request can be taken by phone, fax, or email, and it does not require an elaborate explanation on why you believe there has been an underpayment. Reconsideration requests are normally resolved by a payer’s claims department within a short period of time. They are not time-sensitive, so you can normally ask a payer to reconsider their decision at any time.
On the contrary, provider appeals are never done through customer service. Moreover, submitting an appeal should always be your second step when arguing in favor of additional payment. A provider appeal is a written inquiry reviewed by a payer’s appeals department. It may take up to 60 business days for a plan to review your appeal and issue a new determination. Appeals are time-sensitive, and they are usually mailed or faxed. Insurance can set its own timely filing limit for an appeal. In most cases, it is 90 calendar days since the date of denial.
What should be included in an appeal?
Your written appeal needs to contain a clear description of a payer’s denial reason, and an elaborate list of arguments on why you believe that the payer has acted inappropriately when processing your claim. It is recommended to enhance each argument with a clinical/reimbursement policy issued by the CMS or a payer itself. Cases involving a lack of medical necessity should be appealed along with clinical records for the encounter.
Just a quick reminder – our Billing Department account representatives can take care of your appeals.
Our expertise allows us to deal with every denial regardless of its nature.
Contact us through the form at the top of this page.