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How to Start the Medical Billing Appeal Process

In most medical billing disputes, the most efficient first step in the appeals process is to make a phone call to the payer. Ask the representative whether the issue can be resolved; if not, seek direction to initiate the appeal or reconsideration process. If you’re dealing with a commercial payer, the payer may have a reconsideration form on its website that providers can use to challenge a payment decision.

Writing letters takes time, and then it takes even more time for the recipient to read the letter, verify the argument, and then forward the claim to be corrected. If the problem is simple, you may be able to have the claim sent back simply by calling the payer.

Before discussing the claim with you, the provider representative — the person employed by the payer to work with you regarding disputes —verifies your need to know. Expect the representative to ask for the following information:

  • Your name.

  • The name of your company and tax ID number or the NPI (National Provider Identifier) number.

    The NPI is the ten digit number required by HIPAA (Health Insurance Portability and Accountability Act) to identify providers in electronic transactions.

  • The patient’s ID (the identification number assigned by the payer), name, and date of birth.

  • The date of service in question.

  • The billed amount of the claim. (This is the dollar total of the claim, not what you are expecting to be paid.)

After you verify your need to know, you have the opportunity to tell the provider representative why the claim has not processed correctly. Often the representative can look at the claim, look at your contract, and verify what needs to be done. If that happens, the representative can usually send the claim back to the processor with instructions to reprocess.

Sometimes, the phone call alone may be enough to resolve the issue. If it’s not, you need to follow up with a letter.

Make sure you document all phone conversations in the patient system or billing software. Note who you spoke with, what the agreement was, and the reference number (get this number from the provider representative; it documents the conversation on the payer’s end). This kind of documentation is essential when a potential filing issue arises.

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