Become an Annual Subscriber and Get $350 Off + Amazon Gift Card SHOP NOW - Ends April 15

Include These 5 Items in Your Appeal Letter to Achieve Success

Share: Share on Facebook Share on Twitter Share on LinkedIn

Include These 5 Items in Your Appeal Letter to Achieve Success

Share: Share on Facebook Share on Twitter Share on LinkedIn
denied claim appeal letter

Every medical practice has been there: You get a notification from an insurer that your claim is being denied, downcoded, or held for more information. In many cases, this can mean thousands in lost reimbursement for a service you’ve already provided. Therefore, your best bet is to appeal inappropriate denials so you can recoup the money you know you’re entitled to.

Unfortunately, however, most insurers don’t have a standard appeal form, so it’s up to you to determine how to fight your claims, and what to say in your denied claim appeal letter. If you appeal incorrectly, you could waste hours only to be denied again — and if you wait too long, your appeal window could close, leaving you with no recourse.

To get a handle on how to craft a winning denied claim appeal letter, check out the five elements you must include in your letter, and a few factors to leave out.

1. Include the Patient’s Information and Claim Number

Your payer is likely to get hundreds of denied claim appeal letters every day, so you can’t simply submit a letter with the patient’s name and address on it. Much as you would with a claim, you’ll include the patient’s details and the date of service at the top of the claim, along with the claim number, the code you originally submitted, and the patient’s member number.

Example: At the top of your claim, you’ll include:

To: Payer name

Re: John Doe

DOB: 01/01/1986

Member #: XXXXX

DOS: 07/26/2022

Service (CPT): 99205

Under that information, you’ll start the actual letter.

2. Include a Statement About What Was Denied and Why You Disagree

A generic appeal letter will always be disregarded by the payer, because they denied your claim for a reason: They believe they have reason to withhold or reduce payment for the service. So you must show them exactly what you disagree with, and why.

Example: Let’s say the payer denied a claim with E/M code 99205, the highest level of outpatient evaluation and management for a new patient. The denial reason, according to the remittance advice, says that the claim did not support medical necessity to warrant reporting 99205.

Therefore, you would start your letter saying, “I am writing on behalf of our patient, John Doe, to appeal your decision to deny the E/M service listed above. It is our understanding that you are denying coverage on the basis that CPT code 99205 did not support medical necessity.”

3. Share Additional Criteria to Support Your Case

When you’re writing the payer, you must have a reason to support your assertion that their denial was inappropriate, and that could be based on payer directives, information from the CPT manual, or details about the patient that may not have been reflected on the claim.

Example: Using the 99205 denial example above, your letter might say, “Based on the CPT guidelines for evaluation and management services, all criteria were met for reporting this code. Per Dr. Smith’s clinic note, the patient presented with a new diagnosis of pancreatic cancer (C25.2). In addition to this high-risk diagnosis, the patient also presented with an enlarged prostate, along with comorbidities of CAD and ischemic cardiomyopathy. These chronic conditions will impact the medical decision-making for chemotherapy (a high-risk drug).

Contrary to your denial decision, 99205 should have been paid. The note clearly captures the patient’s risk, along with a notation of the time spent (66 minutes) with the patient. The medical decision-making of high complexity (diagnosis points >4/risk of mortality high). Mr. Doe has a newly diagnosed chronic illness that poses an immediate threat to life. The recommendation for chemotherapy is a drug therapy with high toxicity that requires intense monitoring, both of which support a high-risk MDM. This service is noted as a covered benefit in the patient’s plan coverage, and medical necessity has been met.”

4. Bring It Home with a Request for Denial Details

As your closing in the denied claim appeal letter, summarize your appeal and let the payer know that if they continue to deny the service, you want specific reasons why

Example: “If you choose to deny this appeal, we request that you forward a copy of your internal clinical criteria to substantiate your denial and show how it supersedes your written policy and CPT guidelines with reference to this claim.”

Then you should sign and date the letter.

5. Attach Supporting Documentation

In addition to sending the appeal itself, attach any supporting documentation, including the CPT guidelines you believe you’ve fulfilled, the payer’s payment policy that your claim fits into, and full documentation from the encounter.

Check These Appeal Don’ts

When submitting your appeal, you must be truthful and only report the facts. In addition, avoid these practices during the appeal process:

  • Never alter or change diagnoses to get claims paid. The diagnoses on the claim should reflect the patient’s true diagnoses.
  • Never modify documentation to make it look more payable to the insurer. Always send the factual records. If you must modify documentation, create a compliant addendum that the provider signs and dates.
  • Don’t appeal a claim that you have no chance of winning. For instance, if you realize your provider didn’t document the patient’s comorbidities or the total time of the visit, you may not be able to justify the code you reported.

To learn more about appealing denied claims, check out the online training session, Proven Appeals Template, Get Your Denied Claims Paid Fast, presented by Leonta Williams, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC. During the 60-minute training, you’ll find out how to appeal your denied claims properly the first time so you can recoup the reimbursement you deserve.


Subscribe to Healthcare Practice Advisor
Get actionable advice to help improve your practice’s
reimbursement, compliance, and success in this weekly eNewsletter.
  • Hidden
  • Hidden
  • Hidden
  • Hidden
  • Hidden