Don’t Miss These Tips to Win Claims Appeals, Get Paid Right the First Time

Appealing a Denied Health Insurance

Ever get paid for a claim, then hear from the payer that you have to send the money back because they reconsidered the claim and denied it? Ouch! Well, CMS has good news for you — recently released guidance from that agency limits the scope of review for some re-determinations and reconsiderations. That means in the future, you’ll have a better chance of winning appeals when your Medicare claim is denied.

MACS Must Stay Focused, CMS Declares

CMS’s order to Medicare Administrative Contractors (MACs) is that when providers submit appeals after a postpayment review denies them, the review of that appeal must be limited to the reasons directly associated with the denial. According to CMS’s MLN Matters SE1521, MACs and Qualified Independent Contractors (QICs) must comply with this limited scope of review for all redetermination requests they receive on or after August 1, 2015.

Though federal regulations allow contractors the option of looking at new issues during an appeal, this meant providers got inconsistent reasons for denials when they appealed claims denials. Now experts believe there will be fewer denials at the redetermination and reconsideration stage of claims denials. This means that when you appeal a claims denial by providing whatever item the MAC or QIC had deemed missing, such as documentation, the payer can’t turn around and deny the claim for a new reason you were unaware of before.

Note that this limited scope concept only applies to claims denied in a postpayment review or audit. If contractors deny a claim before they pay it, and you appeal that denial, contractors can still “develop new issues and evidence at their discretion,” according to CMS.

Novitas Offers Tips for Avoiding Denials

Wouldn’t it be better to just avoid claims denials in the first place? Novitas Solutions, a Part B MAC that covers 11 states, wants to help! Novitas shared a wealth of information on avoiding the need for an appeal on its website. Here are five great tips for claims success.

  1. Make sure all the information relating to the service is accurate.

Missing just one important piece of the puzzle — like the correct date of service — can lead to claims denials. Check to make sure you’ve included the correct date, place of service, national provider identifier (NPI) numbers for referring and billing physician, procedure code, modifier, and more.

  1. Know your Local Coverage Determinations (LCDs).

LCDs can differ depending on which Part B MAC you are billing, so check them frequently to follow local rules and regulations for services.

  1. Know your National Coverage Determinations (NCDs), too!

NCDs show CMS’s national rules on how to report a particular service. Follow them!

  1. If a modifier applies, use it!

For example, append Modifier 25 when your provider performs both an E/M service and another service at the same encounter.

  1. Document, document, document, and make sure you send the documentation in!

If you’re using a modifier, for example, modifier 22 (Increased Procedural Services) to indicate services that required significantly more work than typically required. make sure your documentation supports that distinction. Plus, if your MAC asks for more information, comply with those records requests right away. And make sure the provider has signed that supporting documentation!

Novitas offers a long, long list of tips for claims success. To read them all, hop over to, choose a region, then click “Appeals.”

How About You?

Got any tips for getting claims paid fast, the first time? Let us know in the comment box below.

Avoid Claims Denials With Physician Coder

When you process insurance claims, you worry about ensuring that each claim is clean every time. Fortunately, SuperCoder offers Physician Coder, with its CMS 1500 Real-Time Scrubber that shows you errors instantly so you can correct the claim before it goes to the clearinghouse. Physician Coder also helps you find relative value units (RVUs) for a specific CPT code so you can set practice fees and bill multiple surgeries in the right order. Physician Coder helps you report PQRS measures for reimbursement, too, with a CPT®/ICD ↔PQRS Crosswalk that shows PQRS measures associated with ICD-10, CPT®, and HCPCS codes. And of course there’s my favorite feature, Code Search, which lets you quickly search across our database to find the latest code information for CPT®, HCPCS, ICD-9, and ICD-10 codes. There’s so much more in Physician Coder to make your practice’s reimbursement cycle management more efficient and effective. Check it out!


Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

, , , , ,

Leave a Reply