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How to Compose a Medical Billing Appeal Letter

In medical billing, sometimes, a phone call just isn’t enough. You may need to compose an appeal letter. The issue may be complicated and easier to document in writing. For example:

  • If the problem is a bundling issue, a written appeal is always necessary. You can’t argue unbundling without supplying the documentation that supports the request for additional payment.

  • If you are dealing with a third-party pricing issue, you may need to send a letter to the payer and the third-party pricing agent.

  • If taking legal action becomes necessary, you need the written proof of your attempt to secure correct payment.

What to include in your letter

In your appeal letter, be sure to include the claim number, patient name and ID number, the date of service, and the amount billed.

Begin the body of the letter by outlining your expectations for claim settlement. Then explain why the claim should pay per the expectations you describe. After that, reiterate your expectations, including the time frame that payment is expected and the follow-up action you’ll take if the claim doesn’t reprocess as you’ve outlined.

Be prepared to follow through on any implied actions. If you say that the matter will be referred to your attorney in 30 days, then send it as promised. Similarly, if you say that the issue will be sent to the insurance commission in 30 days, do it.

Use reconsideration request forms

Some commercial payers or insurance companies have something called reconsideration request forms available on their websites. That’s just a fancy way of saying “claims form,” but you get the picture. Depending upon the company’s preferences, you can submit some forms online; others must be mailed or faxed.

These standard forms are for simple appeals — called first-level appeals — that are contractually based and need very little argument. If this initial appeal is denied, you need to file a formal second-level appeal, which is a letter that outlines your request and the reason for your position along with the supporting documentation.

Other stuff to know about an appeal letter

When you send an appeal, keep the following points in mind:

  • Notify the intermediary, if one was involved, that the payer has refused to honor the negotiated settlement.

  • Prior to sending the appeal, call the payer to verify where the appeal should be sent. If the claim was priced by a network and paid by a commercial payer, send the appeal to both and let them know that each has been notified of the payment deficiency.

  • Check to see whether the network priced the claim or whether the payer simply accessed the network itself.

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