What is the most effective way to appeal a denied claim?

1 Know the reason

The first step to appealing a denied claim is to understand why it was denied in the first place. You should receive an explanation of benefits (EOB) or a remittance advice (RA) from the payer that states the reason for the denial and the codes that correspond to it. You should review the EOB or RA carefully and compare it with your original claim and documentation. If you find any errors or discrepancies, you should correct them and resubmit the claim. If you disagree with the payer's decision, you should prepare to appeal it.

3 Write a letter

Writing a clear and concise letter is the third step to appealing a denied claim. This letter should include the patient's name, ID number, date of service, and amount of the claim, as well as the reason for the denial and code that indicates it. Additionally, you should explain why you disagree with the denial and provide evidence that supports your argument. You should also include references to the payer's policies, medical necessity, standard of care, or coding guidelines that justify your claim. Moreover, your letter should request a reconsideration or reversal of the decision and include contact information of the person or department handling the appeal. Lastly, don't forget to sign the letter with either your own signature or an authorized representative's.

4 Attach the documents

When appealing a denied claim, the fourth step is to attach relevant documents that support your letter and your claim. These may include a copy of the original claim and the EOB or RA, the patient's medical record, chart notes, progress notes, lab results, or other clinical documentation. Additionally, you should attach a prior authorization, referral, or prescription if applicable. Furthermore, you should provide a copy of the payer's policies, guidelines, or criteria that apply to your claim as well as any peer-reviewed articles, studies, or guidelines that demonstrate the medical necessity or standard of care for your claim. Finally, include any correspondence or communication with the payer regarding the claim or appeal.

5 Submit the appeal

The final step to appealing a denied claim is to submit the appeal to the payer in the appropriate format and within the deadline. You should send the appeal by certified mail, fax, or email and keep a confirmation of receipt. You should also follow up with the payer regularly and monitor the status of your appeal. You should expect to receive a response from the payer within 30 to 60 days, depending on the level and the complexity of the appeal. If you receive a favorable decision, you should verify that the claim is paid correctly. If you receive an unfavorable decision, you should consider whether to pursue the next level of appeal or seek legal advice.

6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?