The Newsletter of  
                                                                             D E K A Y E  Consulting, Inc.

EXAMPLES OF APPEAL LETTERS from   
CLAIMS DENIAL APPEALS PROCESS, By Jeffrey W. Shutak, CHFP, Patient Accounts Manager, The Memorial Hospital, North Conway, NH

March 13, 2000
Name, RN
Appeals Coordinator (title)
Address
Address
Re: Appeal of Denial by…(Name of Insurer)

Subscriber Name: (Name of Subscriber)
Patient Name: (Name of Patient)
Date of Service: April 28, 1999
Certificate #: 0987654321
Pre Certification #: 1234567890
Patient Act #: 333342400
Amount of Claim: $3,303.38

Dear (Name):

I am writing to appeal the decision of (Name of Insurer) to deny benefits for (Patient Name). The reason for the denial is "that (Name of Insurer) had no authorization on file for this patient" (see attached copy of denial).

The denial was issued retrospectively despite a pre certification review and approval by (Name of Insurer) prior to the service. In addition, partial payments have already been made by (Name of Insurer) on this account.

The (Name) Hospital called (Name of Insurer) on April 28, 1999 and obtained pre certification number 1234567890 from (Insurer Representative) for the patient, (Patient Name).

I do not believe it is reasonable of you to issue these types of denials after a pre certification has been issued and partial payments have been made. I am requesting that you reevaluate your position in this particuliar instance and all similar circumstances should the situation reoccur.

You may reply by letter or phone to me at 603-xxx-xxxx, extension 544. Thank you.

Dear (Name):

I am writing to assist our patient (Patient Name) in appealing the decision of (Name of Insurer) to deny benefits for his hospitalization of May 4^th, 2000. The rationale for the rejection is that (Name of Insurer) states they had no prior authorization on file for this date of service.

Our records indicate that The (Name) Hospital called (Name of Insurer) on May 4^th 2000 in an effort to obtain a pre certification approval for (Patients Name) admission. We spoke to an individual by the name of (Payer Representative). (Payer Representative) advised us that this policy had been terminated effective March 31, 2000. Therefore making the pre certification unnecessary, since we were told by (Name of Insurer) there was no coverage in effect at that time.

In subsequent investigations and via billings to the patient we learned that coverage was in effect at the time of service. We then billed the claim as instructed by the patient, the claim was consequently denied. We do not believe we should be penalized for this denial based on lack of pre certification for information contradictory to what we were told by (Name of Insurer).

I would appreciate it if you would, based on this information, reconsider payment of this entire claim, less applicable deductibles and co-insurance's.

You may reply by letter or phone to me at 603-xxx-xxxx, extension 544. Thank you.

Dear (Name):

I am writing to appeal your decision to deny payment for emergency services provided to Mr. (Patient Name) at The (Name) Hospital from DOS August 5, 2000 through August 7, 2000.

(Patient Name) was treated in the emergency room of The (Name) Hospital at 7:20 p.m. on August 5, 2000 as a result of severe injuries sustained while rock climbing in the area. (Patient Name) injuries required him to be treated both in the emergency room, the operating room and to be held for post surgical observation at The (Name) Hospital.

Since this was an emergency admission, occurring in the evening, there was not an opportunity for The (Name) Hospital or the patient to obtain prior authorization from your company prior to emergency treatment. In addition, to comply with EMTALA regulations, we were required to treat (Patient Name) injuries immediately.

The patients Mother attempted to contact you that evening to advise you of his emergency treatment but was unable to speak to anyone to report this emergency situation.

On the morning of August 6, 2000 a representative from the Central Registration Department at the hospital called your company and left a message for an agent of your company to contact us regarding (Patient Name) admission. The phone call was not returned.

Since we did not receive a reply from you we attempted a third time to contact your company on the morning of August 7. On that occasion, we spoke to an individual by the name of (Payer Representative). (Payer Representative) advised us that a pre-certification approval was not a requirement for ambulatory surgery for (Patient Name) emergency treatment. In addition, a pre-certification authorization was not obtained because of the emergency nature of (Patient Name) services.

The (Name) Hospital is appealing your decision to deny benefits to (Patient Name) because of the aforementioned circumstances. If you have additional questions regarding this matter, please contact me at 603-xxx-xxxx extension 544. Thank you.

Dear (Name):

I am writing to appeal the decision of (Name of Payer) to deny benefits for (Patient Name) The denial was issued retrospectively despite a pre certification review and approval by (Name of Payer) prior to the service. Here are the pertinent facts of the account:

My question is why did you say on 3/2/2000 that the claim was rejected because the notes were not received, then reverse yourself and say the claim was rejected because the notes were received late? It would appear to me that you are seeking to deny the claim regardless of The (Name) Hospital's efforts to comply with your requests.

In addition, you initially said that this claim was denied because no pre certification was obtained. When we pointed out that we had a pre certification you denied the claim because of the lack of clinical notes. When we pointed out that we had submitted them, you denied the claim because they were not received in a timely manner.

I am sure that you will agree that claim appeals are a very costly and time-consuming process for everyone. But I see a pattern where we have had four claims for MRI services denied within the past several months even though we obtained pre certification approvals on all of these claims.

I am not aware of any contract language that stipulates that (Name of Payer) can deny a precert retrospectively. In addition, if we had been advised prior to the service that this would be a non-covered service, we could have passed this information onto the patient.

I do not believe it is reasonable of you to issue these types of denials after a pre certification has been issued. I am requesting that you reevaluate your position in this particuliar instance and all similar circumstances should the situation occur.

You may reply by letter or phone to me at 603-xxx-xxxx, extension 544. Thank you.

Appeal Letter Example #5

Dear (Name):

The (Name) Hospital filed appeals dated August 17th, 2000 on behalf of the two patients identified above. On September 27, 2000 we received a response from you (copies attached) denying the appeals based on lack of timely submission of these claims.

An examination of our documented billing records indicates these claims were initially filed in a timely manner. The claim for (Patient Name) was originally filed eleven days post discharge. The claim for (Patient Name) was filed seven days post discharge.

Consistent with the (Name of Insurer) Billing Manual, timely filling is defined as "within 60 days of the service date" (Billing and Reimbursement, Section 9-4). The billing manual, nor our own provider contract, addresses claims follow up. (As an aside we have billed the two claims in question a total of six times).

The (Name) Hospital does not believe it should be held liable for lost or misplaced claims by the (Name of Insurer). I am respectfully requesting that you reexamine your denial decision. Thank you

You may reply by letter or phone to me at 603-xxx-xxxx, extension 544. Thank you

.

Appeal Letter Example #6

Dear (Name):

I am writing you in a final effort to have this claim paid. We have submitted this claim to (Payer Name), a total of five times. We have been told on two occasions that you need an itemized billing for this service.

The initial billings were submitted by the standardized electronic submission format to (Payer). We were subsequently notified that (Payer) has no record of the claim. We submitted again electronically and heard nothing. We then submitted via a paper UB-92 and again nothing was processed. We were then advised that we must submit an "itemized" bill. I have checked our billing protocol and contract with (Payer) for the submission of claims. We have followed the standard billing instructions as outlined in the UB-92 billing manual.

I feel it is unfair to penalize The (Name) Hospital and the subscriber for (Payer) continued neglect in responding to our billings. Five resubmission's for this claim is cost ineffective and very time consuming. The subscriber has called the hospital on several occasions to inform us that we are billing incorrectly and that we must submit an itemized billing to you.

Please respond as to what course of action The (Name) Hospital should pursue to have this claim paid. If there are standardized, National Uniform Billing formats other then what we are following, please forward us those formats. We want to have this claim settled on behalf of the patient and the provider. Thank you.

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