How do you structure an appeal letter for a denied claim?

The first step in writing an appeal letter is to understand the insurer's policies and requirements. Review their guidelines for formatting and content. Identify the correct contact person, address, and reference number. Use a professional, courteous tone, avoiding emotional or accusatory language to ensure a respectful and effective appeal.

The second step in writing an appeal letter is to clearly state your purpose. Explain why you are appealing the claim denial and what you are requesting. Include key details like the date of service, patient and provider names, and the claim number. Attach supporting documents, such as medical records or test results.

When appealing denied claims, first review the EOB to confirm the denial reason. Then you can accurately and factually rebut the denial. If it is a matter of lack of auth, then you can simply resubmit the claim with documentation of the authorization already being obtained. However, if it is a matter of medical necessity, then you must carefully review and utilize the pertinent payer criteria to prove medical necessity. In instances where criteria may not be met, you can still appeal but you must provide evidentiary support for the clinical decision.

The third step in writing an appeal letter is to provide facts justifying your claim. Use specific, objective information from credible sources like clinical guidelines or peer-reviewed literature. Explain how the denied service was medically necessary and appropriate for the patient. Address any errors or misunderstandings that contributed to the denial.

In my experience, highlighting the benefits is less relevant for claim appeals. If it is a medical necessity appeal then yes, highlighting the benefit to approval can be important but in cases where a claim was denied for a non-clinical reason, the payer is not likely to consider this. Stick to addressing the reason the claim was denied (inaccurate code, lack of authorization, timeliness).

The fourth step in writing an appeal letter is to highlight the benefits of claim approval for both the patient and insurer. Emphasize how the service improves health outcomes, quality of life, and satisfaction while reducing complications or costly hospitalizations. Explain why alternative treatments were unsuitable or unfeasible for the patient.

The fifth step in writing an appeal letter is to request a timely response. Indicate when you expect to hear back and your preferred contact method. Include your contact details—name, title, phone number, and email. Thank them for their attention and cooperation, and express hope for a positive outcome.

The sixth and final step in writing an appeal letter is to follow up diligently. Record all communication details, including dates and content. Regularly check the status of your appeal and request updates or clarifications as needed. If responses are delayed or unfavorable, consider escalating the appeal or seeking external review.