Here’s an appeals template letter and checklist to help health care organizations avoid common errors when they’re rebutting claim denials.[1] It was developed by Taryn Schraad, president of BAC10 Solutions LLC, and first appeared on the website of the Association for Healthcare Denial and Appeal Management (AHDAM). She suggests writing appeals on the official letterhead of the organization. Contact Schraad at tdschraad@gmail.com or contact@bac10solutions and visit AHDAM at https://bit.ly/3jbXu93.
Sample Appeal Template
<<Use Official Provider Letterhead and Logo>>
<<Appeal Date>>
<<Provider Name>>
<<Provider Address>>
Attention To: <<Appeal Author, Title, Department>>
<<Provider fax number or phone number>>
RE:
<<Member/Patient Name:>>
<<Member’s insurance ID:>>
<<Claim number:>>
<<Dates of Service:>>
<<Encounter or account number:>>
<<Disputed dollar amount: $>>
<<Authorization Number:>> (if applicable)
Begin by listing the reasons you, the provider, are writing the appeal. Indicate what level of appeal you are writing and highlight the main points of the denial you are disputing.
<<Provider name>> submits an Appeal Level <<1, 2 or 3>>, and disputes <<Payer name>> denial because,
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Medical services supported the treatment, and care of <<insert the services or condition being denied>>…
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Condition <<Diagnosis code and code description>> is clinically supported in the medical record due to…
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<Provider name>> requests a peer-to-peer review of this claim as << Payer>> has shown no proof that a licensed medical professional has conducted this review as required by <<insert your participating agreement or federal and state regulations governing such>>.
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<< Payer>> has not provided any protocols or policies mandating that <<Provider>> use in determining code selection;
Follow the list of the appeal reasons above and begin writing your appeal, explicitly speaking to the following:
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The primary focus of the denial and why your medical record and services directed at the treatment and care of the condition are supported.
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Cite the ICD-10-CM Official Guidelines for Coding and Reporting and Coding Clinics that support the code assignment and sequencing. Reiterate your request for a peer-to-peer review of the denial.
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Cite contractual rules, protocols, policy requirements, or state and federal regulations the payer and provider must abide by.
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Use footnotes, citations, and page numbers for ease of review.
Run through this checklist before you submit an appeal:
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Was your claim filed timely?
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Is your appeal filed within timely filing limits?
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Have you attached only the minimum necessary documents of the medical record to support your appeal?
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Have you attached only the remittance advice or explanation of benefits for the patient in question?
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Are you a participating or nonparticipating provider during this date of service?
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Have you followed your organization’s policies and procedures for a HIPAA-compliant appeal submission?
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Have you included a complete signature line should the payer need to contact you with any questions?
Sincerely,
<<Appeal author’s name, and credentials>>
<<Appeal author’s address, phone and email>>
<<Provider’s URL address>>
