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Claim Denials: Steps to Writing an Effective Appeal Letter

December 14, 2017
Compliance By Armi Hernandez, Consultant

Writing an effective appeal letter to contest a denied claim involves time, effort and perseverance. The strategic approach of formulating the appeal letter requires a clear understanding of why the claim was rejected. The reason for the denial is the starting point. Considering this, thoroughly review the medical record within the denied claim period and tab the documents needed to support the claim.

 

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The Body of the Appeal Letter

Begin the appeal letter with the patient’s name, health insurance claim number and indicate the denied claim period. Remember not to forget to specify the reason why the claim was denied. This is needed to clearly provide the basis for the appeal. Include a concise account of the course of events that led to your care of the patient.

The body of the appeal letter should be organized, responding to every reason the claim was denied. Categorize the response by painting a clear picture. Write a story wherein the patient and the care provided are the protagonist, and the denial as the antagonist.

  • Step 1: Identify the pertinent deficits brought about by the hospitalization. Support this by including the patient’s prior functional level and the implications and risks that could occur if the skilled services were not provided.
  • Step 2: Demonstrate why the distinct skills of every health care professional involved in the care of the patient were essential.
  • Step 3: Depict the onset status, comparing it to improvements made within the contested claim period. A good way to do this is by entering the information in a table.
  • Step 4: The statements in the appeal letter should emphasize the clinical necessity of the care provided by referencing it to the documents from the medical record, using attachments.
  • Step 5: Cite specific Medicare regulations and published studies to substantiate the claim.

End the appeal letter by emphasizing the clinical information and supporting statements that refute the denial. Highlight the standards of care that brought about the patient outcome, and in a final direct statement, affirm that the services were reasonable and medically necessary.  

Making a Compelling Case

When you are finished with the appeal letter, make sure you review it several times, and have others on your team review it too. Have you made a compelling case? Did you paint the picture of why this patient deserved to receive the care? Make sure you have included everything. This is your opportunity to submit all necessary information for this appeal. Check the details. Are all copies legible? Are all signatures readable? Have you attached a signature log? Are the pages numbered, and is the information in order?

Finally, before sending in your appeal letter, always make a copy. Request a certified mail receipt at the time of mailing, and always track the mail.  

Were you notified of a denied claim? Make sure you're appropriately reimbursed for the care you've provided. LW Consulting, Inc. can help. 

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