Insurance Denial Claim Appeal Guidelines.

What is Appeal Request 

An appeal is a request to change a previous adverse decision made by Insurance. An appeal is necessary when a payment on any one date of service/and or CPT code has been short paid, or denied, either formally or on the explanation of payment

Why claims appeals are a critical practice component

To determine whether a reimbursement you receive is accurate, auditing health insurer payments is essential. In the long term, auditing health insurer payments will help secure your practice’s financial viability. Many practices lose revenue every day due to partially paid, delayed and denied health insurer claims that the practice does not challenge or even notice.


After completion of the retrospective review process contracting providers may appeal certain pre and post-service claim denials. Only claims denied as not medically necessary may be appealed on the provider’s own behalf as set forth in the policies and procedures. When BCBSKS requests records to support a claim denial, but does not receive them within the 45-day time limit, the service will be denied not medically necessary and will be a provider write-off. The provider may be designated as the member’s authorized representative for appeal purposes according to the terms of the member’s contract.

NOTE: Medical policies including Content of Service (COS) as described in BCBSKS Policy Memos 1-12 or provider’s obligations specified in their provider contracts are not considered eligible claims appeals as outlined in Section III. DENIED CLAIMS APPEALS PROCEDURE. Annually, BCBSKS outlines any changes to the Policy Memos and forwards them to providers for their review. Once providers accept these changes, they are part of the provider’s contract and therefore not considered for claims appeals. Providers disagreeing with any policies should submit their position and supportive documentation to BCBSKS staff for future consideration.

What is lost when practices do not appeal

Health insurers save money when they partially pay, delay or deny a claim payment because only a small percentage of physician practices routinely pursue an appeal. When you do not audit and appeal health insurers’ inappropriately paid or denied claims, your practice loses not only revenue but also the opportunity to recover overhead expenses. Challenging inappropriate payment of claims through the health insurer’s appeal process also demonstrates that you have made an effort to correct the health insurer’s inaccuracy. Appeals efforts could lead to a change in the health insurer’s business practices.

Finding reasons for denial

Insurance will deny the claim for any reason and first we need to understand the Denial fully and we prepare the denial letter and submit the claim with attached proof. Here i have listed some of the common insurance denial.

1. Inadvertent practice errors
2. Health insurer processing errors
3. Lack of recognition of modifier 25
4. Lack of recognition of modifier 59
5. Health insurer incorrectly downcoded CPT
6. Health insurer applied a PPO discount when a contract does not exist
7. Medical necessity denials
8. Request for in-network coverage
9.Coverage Exclusion or Limitation
10. Coverage Administration (i.e. copay, deductible, etc.)
11 .Maximum Reimbursable Amount
12.Inpatient Facility Denial (Level of Care, Length of Stay)
13.Mutually Exclusive, Incidental procedure code denials
14.Additional reimbursement to your out of network healthcare professional for a procedure code modifier
15.Experimental/Investigational Procedure
16.Medical Necessity
18. Benefits reduced due to re-pricing of billed procedures

Requests for an appeal should include:

1. This completed form and/or an appeal letter requesting a review and indicating the reason(s) why you believe the adverse decision is incorrect and should be changed. If you submit a letter, please include all the information that is requested on this form.

2. A copy of the original claim and explanation of payment (EOP), explanation of benefit (EOB), or initial adverse decision letter, if applicable.

3. Any documentation supporting your appeal. For adverse decisions based upon lack of medical necessity, additional documentation may include a statement from your healthcare professional or facility describing the service or treatment and any applicable medical records.

Most of the insurance has their own appeal form, Get the appeal form and fill up the form with required attachments. If you do not use the appeal request forms, you must provide a signed cover letter with the following minimum information:

* A request for appeal or reconsideration of a denial,

* Your name, address, and phone number;

* The member’s name, DOB, and policy number;

* Dates and types of services requested, and the provider rendering the service;

* Reason that you are requesting appeal or believe denial should be overturned.

Appeal requests that do not contain sufficient information will not be processed.

Here is the sample appeal Letter.


Provider/Appellant Information Patient Information
Provider Name:_____________________________ Name: __________________________________
Contact Person: ___________________________ ID Number: _______________________________
Address: __________________________________ Date of Birth: ______________________________
City, St. Zip:_______________________________ Services Provided
Telephone: ________________________________ Date(s) of Service: __________________________
Type of Service: ___________________________
Reason for requested overturn of denial:
Signature: _______________________________________ Date: _______________________
Print name: ___________________________________ Phone Number: ______________________
The Appeal Determination will be mailed to the person/ address on this form or the appeal letter.

Finally submit the appeal through mail or Fax. Keep on do the follow up with claim and get paid.

Ten important tips for appeal the denial claim

The following steps may help if the health insurer requires a formal appeal letter:

Step 1. If your practice participates in the health insurer’s managed care product (e.g., PPO, HMO or POS), review your contract for the claims appeals processes and monitor the health insurer’s compliance. Some health insurers may require specific forms for submitting claims appeals.

Step 2. Prepare an appeal letter that includes the patient’s name, subscriber’s name, health insurer identification and insurer numbers, date of service and the reason that you are challenging the health insurer denial.

Step 3. Thoroughly support and document your argument. Use both subjective information (i.e., patient’s chief complaint, physician’s personal comments) and objective data (i.e., medical record findings) and gather supporting documentation.

Step 4. Once you prepare the claim appeal letter, ask the treating physician to review it for appropriateness, along with the supporting documentation, before signing the letter. Make sure you include the physician’s signature and credentials in the claim appeal letter. In the case of a medical necessity or a chronic inappropriate administrative denial, you may choose to forward all relevant documentation to all involved parties. (See sample notification letters.)

Step 5. Identify the name of the health insurer’s contact person who should receive the claim appeal for review.
Be sure to address the claim appeal letter to the appropriate health insurer representative so that a specific person will be responsible for a reply. If you do not know a contact person, call the health insurer and request the name and address of the health insurer representative or department to which you should address the claim appeal. Also, ask the health insurer representative the expected time frame for processing the claim appeal letter. This information will help you determine the appropriate time frame for follow-up procedures.

Step 6. Request a review of the claim appeal letter by a physician of the same specialty.

Typically, the reviewing physician from the health insurer will phone the treating physician to discuss the case and determine whether medical necessity approval is warranted. Whether a physician reviewer or other health insurer medical review staff determines an approval, you should record the reviewer’s name and the case reference number in the file and in your health insurer follow-up log. This information will be critical if the health insurer subsequently denies the claim as not medically necessary..

The health insurer may still deny a claim based on medical necessity , despite the fact that you obtained pre-approval and correctly coded the claim with the ICD-9-CM code the health insurer representative indicated as the covered condition for the CPT code billed. The physician reviewer may perform a telephone review to avoid a formal written appeals process for these types of denials. Written appeals can be time-consuming for both the health insurer and your practice, resulting in lengthy review processes that can extend for three months or longer.

Step 7. Consider faxing the documentation—determine whether the health insurer will accept a faxed claim appeal letter and supporting documentation.

Submitting a faxed claim may expedite the health insurer review and auditing processes. When sending a fax, keep a copy of the fax confirmation report that indicates the health insurer successfully received the fax.

Step 8. If the health insurer does not accept faxes, send the claim appeal letter and supporting documentation via certified mail, return receipt requested.
You may find a return receipt with a signature from a health insurer representative may prove helpful, especially if the health insurer does not acknowledge the claim appeal letter.

Step 9. Consistently follow up with the health insurer representative on the status of the claim appeal review until you receive appropriate payment.

Step 10. Take a proactive approach—maintain a file that contains the common claims denials that are based on medical necessity and other common administrative denials and supporting documentation and keep claim appeal letter templates that will help simplify your appeals process.

Finally Best of Luck !!!

Medicare appeal Process

What is considered a Reopening? (Not an inclusive listing)

•  Diagnosis changes/additions 
•  Date of service changes 
•  Procedure code changes 
•  Unit changes
•  Certain modifier changes/additions For a listing of proper reopening requests refer to

How to Expedite Appeal Payment

In order to expedite the appeals process, ensure the request is complete and accurate. The following criteria are required on the Redetermination Request Form:

•  Beneficiary’s full name
•  Health Insurance Claim (HIC) number 
•  Date of service 
•  Signed  Redetermination Request
•  HCPCS/Procedure Code 

Ensure all supporting documentation is submitted with  your request. Refer to ) to determine the necessary medical documentation. CMS requires Noridian to order missing documentation via letter or a phone call to your facility. If all necessary documentation is not included in the request it could potentially delay your request an additional 14 days or longer. If no response is received 
from Noridian’s request, your appeal will remain denied.

Ensure supporting medical documentation contains the  following prior to submitting the request:

•  Submit the request to the correct contractor
•   Request is legible
•  Correct date of service
•  Valid medical documentation signatur

What is considered a Redetermination?

If a provider disagrees with Medicare’s decision on how a claim was initially processed, an appeal may be requested. Prior to submitting an appeal, consider if a 
Telephone or  Written Reopening could be requested.

How do I submit my Redetermination?

Submit redeterminations by one of the following:

Endeavor (FREE & Efficient):

Fax:  1-701-277-7852

Noridian Healthcare Solutions 
Attn: Redeterminations 
PO Box (select from table on form) 
Fargo ND 58108-(select from table on form)

Overpayment Redeterminations Mail:
Attn: Overpayment Redeterminations 
PO Box 6785 
Fargo ND 58108-6785

RA Redeterminations Mail:
Attn: RA Redeterminations 
PO Box 6789 
Fargo ND 58108-6789

Select the proper Type of Request such as CERT,  Redetermination, Redetermination Due to Overpayment,  RA or ZPIC on the Redetermination Form

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