Reconsideration or Appeal

Don’t assume every insurance payer follows the same protocol. Research each payer your practice bills and build a running spreadsheet with a tab per payer. List the pertinent Information for each payer under their tab.

What should be listed? Glad you asked! Here are a few suggestions. Adjust according to the needs of your practice:

• Point of contact: phone, email and fax numbers
• Codes your practice uses that must have modifiers with the modifier. *See payer site for details.
• Timely filing deadlines for submitting the original claim & corrected claim. Also list the address to submit proof of timely filing and any deadlines this filing may have.
• Define Reconsideration per Payer. *Some payers will say a reconsideration is a first level appeal.
• Appeal: points of contact, timeline, is there more than one appeal that can be filed?
• Does an appeal require doctor or patient authorization?

Now let’s set yourself up for success by applying some strategical methodologies:

• When was the claim denied/partially paid? *Know your timeline.
• Why was the claim denied/partially paid? *Include all follow up notes and call reference numbers with the form of contact used.
• Does the documentation align with services provided?
• The more details in the charting, the less interpretation you leave for the reviewer. Paint the clearest picture of patient care.
• What to send:
  • Detailed medical documentation: EOB(s), note(s), imaging, labs, referral(s), letter of medical necessity, letter asking for reconsideration/appeal with rationale and detailed account of the follow up on the claim.

Keep in mind a computer processes the claim. If the claim codes cannot be computed due to the diagnosis codes, CPT codes and modifiers not aligning with the data programed into the payer's clearinghouse a denial/partial payment is likely.

A person reviews reconsiderations and appeals. This process leaves a window of their interpretation of the documents you submit. If you have detailed records of the services provided there is a better chance they will understand the extent of the services rendered. This part is a must!!! You must include documentation refuting the denial reason(s).

The goal is to receive reimbursement for the services rendered.

Lastly, what are your practice’s policy on claims that have exhausted all avenues of reimbursement?

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