Our Appeals Process

Insurance companies authorize coverage for services that are medically necessary and appropriate, and pay claims that should be paid. But what happens when they don’t pay? Consumers covered by fully-insured health plans need a way to challenge decisions that seem unfair.

Specifics for Written Appeals

Denials for claims will be in writing which will describe the specific reason for denial. If it is medical necessity, the supporting documentation will need to be attached with a summary statement clearly stated in the written appeal letter sent. All correspondence for denials require certified mail and supporting documents kept on file for each client, and must be made in writing. These written responses are tracked on a master spreadsheet of all appealed claims which include the claim numbers, the certified mail tracking numbers, the dates mailed and the relevant client info.  These will correspond to the notes for each claim which will have updated notes, all files uploaded and appropriate statuses assigned to the claims in our software. These statuses will also include assigned follow up dates for each claim which prompt the assignee through our software automatically to follow up for each claim on the appropriate date to ensure they are not left to expire.

If the carrier is claiming they never received the records, we will provide the tracking info for the certified mail, the phone reference number for the follow up calls and in many cases the recorded audio for the phone calls that were made acknowledging receipt of the records.

Internal Appeals Level 1

As noted above, ignored claims require a phone follow up after 60 days with no action. This is to force the claims to be processed or reprocessed with the updated record request or information. Reference number from the phone call is recorded in Avea, and the recording of the call is stored on our records. If a phone call is insufficient to prompt an amicable reprocessing, the first written appeal will be sent.

Written appeals are an arbitration attempt in which the case for payment is made by the provider and the case for non-payment is made by the carrier. Each one will require a specific letter sent by certified mail noting the claims in question in the letter, or an attached and referenced spreadsheet of the claims, dates of service, exact amounts billed or paid and the exact amount disputed or outstanding. The letter will clearly state what services were rendered by the provider and reference the violation of parity and all applicable case law as to why the service is covered and payment is required. A complaint will be filed with DOBI for non-response at this point while continuing to attempt to collect.

Internal Appeals Level 2

For those denials which are upheld by the carrier upon the first written appeal, the carrier will restate their maintained reason for denial. If they specifically note that the internal appeals process has been exhausted and a level 2 is not available, complaints may be filed with DOBI if there is sufficient support that the denial is in the wrong, and an external appeal may be started.

For all other upheld 1st level denials, the summary may be restated or rephrased with any additional support requested or implied to further make the case that the service should be covered by the carrier and meets criteria for payment. All documentation must support the specific reason for denial that is being upheld.

These issues will vary from case to case and will need to be individualized according to the clinical documentation of the specific client. Often at this level, the insurance company is no longer honoring specific cases and this becomes a formality to exhaust in order to move to an external appeal.

 Exhausting internal written appeals

When there is sufficient evidence to support a covered service dispute for payment with a carrier, we will need to make the case clearly and plainly in writing exercising our rights for full disclosure on how each determination was made, as well as the qualifications of the decider. This must be done in order to attempt to resolve this with the carrier directly. When there is no amicable resolution, we are then able to submit for an external appeal.

External Appeals

Once the internal appeals process is exhausted for each patient, the claims may be appealed one time externally depending on the type of plan and eligibility. In some cases, the appeal may still require a lawsuit following the outcome of the external review.

Each external appeal will be drafted by our team but will also need to include the summary of services justifying medical necessity for the disputed claims. This summary will need to cover every single example of clinical notes for the entire duration of treatment, or any available previous treatment episodes. This statement must be written and signed by qualifying clinician or medical provider such as the medical director. The summary will include all attachments from the previous case for denial, as well as contact information for any treatment team members and their qualifications to support their judgment.

Appeals for insurance fraud will reference state law as it applies to the carrier’s responsibility to make payment to the provider rather than the subscriber.

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