What is the Purpose of the Appeals Process in Medical Billing

What is the Purpose of the Appeals Process in Medical Billing


Any time a patient or their insurance company objects to something about their care, the healthcare provider can use the medical billing appeals procedure to try to get their money back. If pre-certification isn’t provided, the claim may be refused or the payment may be decreased. In the event your insurance company refuses a claim, did you know that you have the right to request that the charge resulting from the denial be amended or reconsidered? An appeal is a name given to this procedure. The right to appeal payment decisions is one of the rights that hospitals make clear to their patients.

What is the Purpose of the Appeals Process in Medical Billing?

What if I told you that if your insurance company denies your claim, you can ask them to reduce or even cancel your bill? An appeal is a name given to this procedure. The right to appeal payment decisions is one of the rights that hospitals make clear to their patients.

 Appeals Process in Medical Billing

Appeals Process in Medical Billing

If you have a problem with your insurance company’s handling of your medical costs, you can file an appeal in two ways: internally or externally. You’ll need to go over the paperwork you’ve gotten from your insurance carrier to begin the procedure. In the event of a denial, the insurance provider must notify you in writing and explain why.

 Process of Composing Medical Billing Appeal Letter

Appealing to your insurance provider can be a daunting task. This does not have to be the case, however, as long as you are organized. In your appeal packet, a clear, succinct letter outlining your counter-argument and referencing the conditions of your policy is a critical component. An advocate or medical professional can write the letter on your behalf.

The letter’s components

  • Patients’ names, insurance policy numbers, and policy holders’ names
  • Patient and policyholder contact information must be up-to-date
  • An explanation for why a request was denied and the date of when the letter was sent.
  • A medical professional’s name and phone number.

Making a strong argument for why the insurance plan should payout on the claim.

  • In what ways do you believe your insurance policy covers the treatment or service you’ve been prescribed? Use plan linage as possible.
  • Request a letter of medical necessity from your doctor, outlining previous treatments and why the treatment in question was recommended and is required in your case.
  • An industry-recognized organization or institution should be able to provide and reference published journal papers or treatment recommendations that demonstrate the positive outcomes and treatment success.
  • Other evidence, such as copies of pre-authorizations if you’ve provided them, second opinions, and so on.

Sending Your Proposal

  • Track submissions: Keep a copy of the fax transmission confirmation if it was sent via fax. Send the letter by certified mail, return receipt requested, if submitting by mail.
  • You should save a copy of your appeal letter, any submitted materials, the delivery or submission receipt, and your record of all correspondence previous to and following the submission of your appeal in a safe and organized place.
  • Your appeal will be acknowledged in writing within 7-10 days, according to the standard timeline. Your insurance carrier should be contacted if you don’t obtain confirmation that your appeal has been received and entered into their database.
  • Cardiovascular Disease Insurance Glossary “Matters of the Heart” For those who suffer from migraine, “Migraine Matters.” Insurance Companies: Appealing a Denied Claim

Forms for requesting a second look should be used

Reconsideration request forms may be available on the websites of various commercial payers or insurance firms. “Claims form” is just a fancy way of stating “claims form.” You may be able to submit some forms online, while others must be sent or faxed to the company.

Forms like this are used in first-level appeals, which are those that are contractual in nature and don’t necessitate a great deal of reasoning. Following a rejection of your original appeal, you must submit an official second-level appeal, which is an official letter outlining your request and accompanying proof.

What else do you need to know about a letter of appeal

  • You should keep the following things in mind when composing an appeal
  • Payer refuses to honor the agreed-upon deal. Inform intermediary if one has been involved.
  • Call the payer before mailing the appeal to be sure you’ve got the correct address. The appeal should be sent to the network and the commercial payer if the claim was priced and paid separately.
  • Check to see if the network charged for the claim or if the payer merely used the network.