Coding Appeals

Coding appeals often center around seeking disclosure of the payer’s coding logic. We use wording such as the following to seek clarification of how the coding decisions were made:

“It is our position that any coding denial should be supported by written coding criteria explaining how newly adopted claim edits will be consistently applied to all related claims. Certain state and federal claim processing guidelines require insurers to provide detailed information regarding benefit calculations, all applicable coding methodologies and all applicable bundling processes. Further, new coding edits should be consistent with nationally recognized and generally accepted bundling edits and logic. If your company utilized published coding guidelines to review the claim, please provide the publisher, product name and version of any software used so that we may assess the accuracy of the information to current coding standards.”

What types of responses does your organization get to these types of disclosure requests? We are working on updated to our coding letters and your input is valuable to drafting effective language for these important appeals.



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Quote From Favorite Book

If you ever find yourself tired of appealing denials and advocating for care, reading the book “Negotiating From An Uneven Table: Developing Moral Courage In Resolving Our Conflicts” may be the verbal elixir you need. Nurse and author Phyllis Beck Kriteck spells out how to maintain a moral backbone in the world of unevenly granted power. As indicated by the title, Kritek speaks at length to the fact that one party holds the upper hand in almost all negotiations. Disadvantaged negotiators find themselves in a number of compromising situations in which they are not prepared. Kriteck suggest “ten ways of being” to help those in such positions to stay at the table and win important concessions. The book introduction serves as a reminder of how important the task is to parties at an extreme negotiating disadvantage:

“The most compelling premise of the book is that the resolution of human conflicts is a moral enterprise that is the responsibility of every human being. To not pursue the creative and constructive resolution of human conflict is to knowingly and deliberately further divisiveness and the harms such divisiveness creates.”

(Source: Negotiating at an Uneven Table: Developing Moral Courage in Resolving Our Conflict (Josey-Bass, 2002) p. 17)

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Appeal Letter Construction Zone

At Appeal Solutions, we maintain more than 1500 appeal letters for medical organizations to use to appeal denied, stalled or incorrectly paid claims (sign up at To constantly improve these letters, we put our letters through a rigorous peer review in order to solicit comments and questions about using these letters for maximum effectiveness. Please comment any suggests or questions you have regarding the following “Appeal Letter Under Construction”: Letter Title: Request For Anesthesiology Peer Review

Dear (contact),

It is our understanding that this treatment was denied pursuant to medical necessity or other specialty care policy or plan coverage limitations. The explanation of benefits did not give adequate information to establish the accuracy of this decision. Therefore, please provide the following information to support this adverse determination.

It is our position that the treatment under consideration involves specialty care and decisions concerning the appropriateness of this treatment should only be made by a board-certified anesthesiologist. Therefore, we request a anesthesiologist review within 15 working days of this request. Please have the anesthesiologist responsible for the review address the clinical review criteria used to assess this treatment, how the treatment failed to meet this criteria and what alternative course of treatment is recommended. If benefits remain denied, please provide the following information which should have been properly disclosed with the initial denial:

  1. Name of the board certified anesthesiologist who reviewed this claim and a description of any applicable advanced training or experience this reviewer has related to this type of care;

  2. Board certified anesthesiologist’s recommendation regarding alternative care;

  3. A copy of applicable internal clinical guidelines applied, if such exists, and the date of development;

  4. An outline of the specific records reviewed and a description of any records which would be necessary in order to justify coverage of this treatment;

  5. Copies of any peer-reviewed literature, technical assessments or expert medical opinions reviewed by your company related to treatment of this nature and its efficacy;

It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non-disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination. Therefore, we appreciate your prompt, detailed response to this request.

Comment and/or suggestions submitted concerning these letters may be used in the development of the Letter FAQS which are soon to be added to the site’s contents.  Thank you for you input!

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Seven Tips To A Successful Medical Necessity Appeal has a number of letters citing state and federal disclosure laws which assist medical providers with demanding more complete information regarding denials. These letters are under the Topic: Benefit Reductions and the Subcategory: State Mandates in the Appeal Letter Repository and include a number of new state-specific disclosure letters.

  1. Request Immediate Peer-to-Peer Review. See Letter Topic Medical Necessity, Subcategory URAC Standards for peer-to-peer request letter.   Access these letters directly.
  2. Request carrier’s medical necessity definition and any applicable published review criteria used in decision. See Letter Topic Medical Necessity, Subcategory State Medical Necessity Terms for your state’s medical necessity letter.  Access these letters directly.
  3. Review carrier’s compliance with utilization review standards and describe deficiencies in appeals. See Letter Topic Medical Necessity, Subcategory State Medical Necessity Terms for your state’s UR regulations letter.  Access these letters directly.
  4. Cite internal quality care guidelines that support treatment. See Users Forum on Contract Negotiation for information on addressing quality care guidelines in managed care contracts.  Access this forum directly.
  5. Cite peer-reviewed literature that supports treatment.  Looking for peer-reviewed information for a specific procedure? Post your inquiry to the Users Forum to see if your colleagues have information regarding where to find supporting literature to include with appeals.  Access the user forums here.
  6. Submit letter of medical necessity from referring physician as well as treating physician. Point out consensus among face-to-face treating providers, if possible.
  7. Pursue all levels of appeal and independent review, where available. See Letter Topic Medical Necessity, Subcategory State Medical Necessity Terms for your state’s independent review request letter.
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An Ounce of Appeal is Worth a Pound of Payment

The health care hue and cry grows louder everyday.

Medical and mainstream publications are filled with stories focusing on the barriers doctors and hospitals face in getting paid in today’s health care environment. Precertification, managed care and tight timely filing deadlines are just some of the hurdles medical professionals must finesse when seeking reimbursement. And if one hurdle is missed, the effort and attention expended in the examining room is all for naught in the business office.

Yet most medical providers ignore what is perhaps the most effective action they can take for securing immediate payment on a denied medical claim – filing an appeal.

“Ninety-five percent of the doctors’ offices I have worked with do not appeal their insurance denials. They do not know how and they do not have the time, ” said Linda Cagle. Cagle is a practice management consultant in Dallas, Texas and the administrator for Surgical Institute, an oncology specialty group.

“My motto is to appeal everything. The worst thing they can say is no.”

Appeals Worth the Effort
At any given time, Cagle has a stack of explanations of benefits on her desk with “Appeal” written boldly across the bottom. She recommends that physician offices spend an hour a week filing appeals. The appeals generated during this time can easily pay that staff member’s salary for the week, she states.

While many carriers do not routinely release the number of claims overturned on appeal, statistics indicate that a well written appeal may be effective in securing payment. According to an article printed by The Dallas Morning News, “Texans File Few Health Care Appeals,” the Texas Department of Insurance is receiving a fraction of the expected number of appeals under a law requiring carriers to pay for external reconsideration of claim denials. The story quotes several insurance industry officials who believe appeal numbers are low because most appeals are favorably resolved through the insurance carrier’s appeal process.

That story states Prudential HealthCare has a two-step internal appeals process and about 25 percent of treatment denials are overturned during the first phase. Of those cases appealed a second time, another 20 to 25 percent are overturned.

These statistics makes it easy for Cagle to commit a staff member to one hour per week of writing appeal letters. And, according to Cagle, she now uses a software solution which allows her to multiply the number of appeals she files each week.

Appeal Solutions’ software product, Power of Appeals, is designed to automate the appeal filing process. This product was the first software system designed to assist medical professionals become more active in the insurance appeals process. Appeal Solutions, based in Blanchard, OK, specializes in insurance claims resolution.

POA Automates the Process
The software consists of more than 1600 appeal letter templates which cover the most common denial reasons, including medical necessity, coverage exclusions and timely filing requirements. Each letter can be edited for any customization the provider desires. The software also has letters citing all 50 states’ timely payment requirements. These letters can be used on claims which are unnecessarily delayed in normal claim processing, a growing problem in health care reimbursement.

Almost all the appeal letters cite state statutes or case law to support the reconsideration request, which many insurance recovery professionals state is crucial for effective claim appealing.

“It is imperative that a physician’s office doesn’t just base their claim’s appeal on billing guidelines but also the regulatory environment that the payor must exist under. I am now encouraging my staff to know and understand state and federal insurance laws and regulations,” said Layton Lang, Chief Operating Officer for Southwest Vascular and Surgical Group in Dallas.

Like Cagle, Lang in one of a growing number of medical billing professionals who, in reaction to recent tightening of healthcare reimbursement requirements, now appeal as many claims as possible.

“More and more payors are hardening up their claim’s processing rules and definitions for ‘clean claims’ in order to increase profit margins in the competitive market. Other plans have been so focused on mergers and growth that their claims processing departments have suffered with claims adjudications lags,” Lang said.

“Our office has experienced a noticeable increase in improperly processed claims due to frivolous delays and denials that were not based on coding or improper filing errors.”

Cagle, too, cites a growing number of denials based on clearly unsubstantial evidence. She said her staff typically appeals an obviously incorrect claims determination by phone. However, phone appeals sometime take close to an hour simply due to the amount of time spent on hold. Cagle believes a written appeal may not only be more effective, but also more efficient and less frustrating to staff.

“From what I have seen in the (Power of Appeals) software, 75 to 80 percent of the over 90 day accounts with insurance, third-party-pay accounts, could be resolved using this tool,” she said.

Easy Implementation
As a practice management consultant, Cagle says she has seen plenty of software advances go unused in a medical setting due to the lack of staff training. Power of Appeals’ implementation, she said, requires little upfront training.

“This is very user friendly. In most offices the need for it to be user friendly is critical because they deal with really difficult receivable systems. In most offices they have a wonderful receivable system, but they use only one or two features,” she said.

Traditionally, medical professionals have expected the patient to pursue appeals on denied insurance claims. Although some still leave this effort solely to the patient, many public service groups are encouraging doctors to become more involved due to the more technical nature of health plans today.

The American Bar Association’s Commission on Legal Problems of the Elderly recently released a report entitled Resolution of Consumer Disputes in Managed Care. In the report, the commission indicated that many managed care enrollees need help in navigating the appeal system.

“An enrollee’s treating physician is most familiar with his/her conditions and care needs. Physicians can be natural advocates for necessary and timely medical treatment. Moreover, physicians have a fiduciary responsibility to patient and advancing patient treatment or expedited review seems a logical extension of that role,” the report states.

However, without a utility to speed the process, many providers are hard-pressed to effectively appeal denials. Power of Appeals allows them to focus more on advocacy.

“All of the medical management systems I have reviewed have possessed limited ability and space to provide proper tracking and reporting on the disposition of appealed claims. Power of Appeals is the first system that provides the tools for accurate claims follow-up and dispute resolution,” Said Lang.

More information about Power of Appeals software is available at

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New Power of Appeals Reports

Are your organization’s financial vital signs hard to take?

The increasing complexity of medical reimbursement means increasingly complex financial health analysis.

Power of Appeals software is the leader in denial management with its powerful database of 1600 compliance-focused appeal letters.  Now, Power of Appeals provides additional financial analysis tools to allow users to achieve better management of a challenging financial variable: denied claims.

Denials hurt healthcare organizations. Dollars lost to denials must be calculated.  Appeals must be tracked and overturned denials should be calculated as well.  Power of Appeals makes it easy to analyze denials cause, appeal success and ongoing account disposition.

To make financials easier to review, Power of Appeals now features a Denials Dashboard with at-a-glance monitoring of Denials Aging and Denial Recovery.  The Dashboard also allows you to quickly assess how your organization stands on Denials By Payer Group, Denials by Denial Type and Denials By Carrier.

Power of Appeals has also made a number of improvements to the Reporting and Analysis feature.  A number of Standard Reports give you the most valuable denial management data.  We have grouped the Standard Reports under the following Management Headings to give you a more complete picture of how the reports help you manage denials:

Day-to-Day Management Review
End-of-Month Performance Reports
User Performance Review
Payer Performance Review
Problem-Focuses Analysis

Keep in mind, Power of Appeals allows you to configure your own reports and retain new report formats under Memorized Reports. However, the Standard Reports display the information most frequently used in denial management and gives you quick access to important account information.

Day-to-Day Management Review
Priority Reports
Analysis By Claim Status with Aging Detail

End of Month Performance Review (AR, Recovery Reports)
Analysis By Account Status
Analysis By Payer Group
Recovery Report By Payer Group

User Performance Review (Employee Performance Review)
Analysis By User
Recovery Analysis By User With Aging Detail
Analysis By User – Priority Status – Review Write Off

Payer Performance Review
Recovery Report By Payer
Analysis by Payer
Denial Type By Payer

Problem-Focused Analysis
Analysis By Claim Status
Analysis By Denial Type
Account Review – High Balance
Account Review – Incorrect Contractual Denial Type
Account Review – Medical Necessity Denial Type
Recovery Report By Denial Type

Learn more about how Power of Appeals Software can help your organization reduce claim denials and underpayments at


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