Ask Yourself These Questions When Working Appeals

ask these questions for more successful appeals

Sometimes it’s the simple things that can help your appeal for a medical insurance claim. Work through these questions to be sure you’re giving a claim its best chance.

Did You Cite the Claim?

You may get your appeal back if you don’t make it clear which original claim you’re referencing. Plenty of coders and billers have learned this one the hard way.

Bonus tip: While we’re in the transition period to MBIs for Medicare, your MAC may accept either the MBI or HICN to identify the patient for appeals and related forms.

Is Your Support for Your Claim Specific?

Appealing claims takes time, and time is money, so you should give it your best effort from the get-go. Use the EOB to see exactly what the payer considers to be the problems, and address those specific areas.

For instance, if the payer needs additional diagnostic information, make sure you give the payer the information from the record that the payer requires. (I hope it goes without saying that you should never make up diagnostic or other medical information to get paid. Submit records that comply with the rules for coding and documentation.)

Is Your Argument Convincing?

If you have to show that your coding is correct, look for supporting articles from publications like AMA CPT® Assistant and AHA Coding Clinic® that hold the weight of authority.

Other examples of possible sources include ICD-10-CM Official Guidelines for Coding and Reporting and instructions included in code sets. Tip: If you feel the decision contradicts the payer’s rules, provide the specific wording in the policy that supports your coding.

Have You Kept a Solid Record of Contact?

While you’re working the appeal, make sure you document each time you have contact with the payer. Include details like the names of the people you communicate with, dates, and summaries of conversations. That way you’ll have complete information to work with and can refer back to the record if you need to provide proof related to the process.

Did You Meet the Timelines Required?

Know your payer’s deadline requirements, and follow them. Some experts advise getting an early start so you have time to do the research and take care of any unexpected happenings. You’re also less likely to forget something if you’re not rushing to get the information in at the last second.

Did You Send It to the Correct Address?

If you’re mailing or emailing, verify the correct address for your particular type of correspondence. If you send the message to the wrong place, the message may not get forwarded to where you want it to go.

How About You?

What advice would you offer about working appeals?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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