How to Exercise All Possible Medical Billing Appeals

By Karen Smiley from Medical Billing and Coding For Dummies

In a perfect world, claims in medical billing always get paid on the first go-round. Because we do not live in a perfect world, you may need to max out your appeals.

If a claim does not pay correctly at first, you can either call or send a written appeal, and the payer will recognize his error and process the claim correctly. Sometimes, even after the phone call and letter, the claim still isn’t processed. In that case, you need to follow the appeals process as outlined in your contract.

Some payer contracts outline their appeals process. Several define the process in steps such as first-level appeal, second-level appeal, and request for outside review as the final level.

When sending a written appeal, send medical records and a copy of the claim along with a copy of the explanation of benefits that was included with the payment. Including the EOB helps the payer identify the claim, including the individual processor. If you don’t include a copy, make sure that the claim number is on the appeal so that the payer can identify the correct claim.

First-level appeals

A first-level appeal may just be a reminder that, according to your records, the claim should have processed a certain way. It’s basically a friendly reminder that the contract wasn’t followed or a discount was applied without a contract. If the problem is purely a pricing issue, this reminder may be all you need, and the payer will correct the error without further delay.

If the problem is that the claim was denied for medical necessity or anything of that nature, include all documentation with your first-level appeal. When you do so, the payer (hopefully) will reverse its decision and reprocess the claim correctly. If your first-level appeal defines the reason for the request along with any supporting documentation, it may be the only appeal you need.

The response time to appeals is often included in your contract and varies among payers. In cases where the payer has implemented new processing software and has multiple claims paying incorrectly (or not at all), the backlog can quickly become months.

If you have not had a reply within 30 days, follow up to make sure that the appeal has been received. Each state has its own prompt payment statute, so your timing also depends on the statutes for your individual state.

Second-level appeals

Sometimes, the payer denies your request. In this case, you need to send another request. The second request is called a second-level appeal. You may need to send this appeal to a different address, or you may be able to simply mark it “second level” in order to identify that you have asked for resolution once already.

A second-level appeal is more formal. In it, make sure you do the following:

Clearly define the problem and note that you have asked once already without success. You may even include a copy of your original appeal.

In a second-level appeal, if you can state your case in a different way, try to do so. Sometimes simply rephrasing your words makes a huge difference.
Include all documentation. This documentation would include things like the EOB, medical records, applicable invoices, and a copy of the contract (or the applicable section of the contract). (Note: If you send a copy of the claim, make sure to mark it “COPY.”)

Check your contract before sending a second-level appeal. Some payer contracts specify that the second-level appeal is the final level, and if it is denied, no further appeal options are possible. In this case, check your contract for options. The contract may identify a third-party mediation process for disputes if the dollar value is high enough. If you’re dealing with a non-contracted payer, you can involve an attorney.