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Five Steps to a Successful Appeal

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A well-prepared, properly documented appeal saves time in the long-run and can help improve chances of achieving the desired outcome.

1. Work with the payer first.  If the appeal is for non-covered/denied charges, benefits/eligibility issues or bundling of procedure codes, you must submit it first to the payer. 

2. Provide documentation.  Be sure to include basic information such as the date of service, patient identifiers (including date of birth), provider name, billed charges, denied charges, etc.  Include a copy of the claim, the original EOB and any subsequent EOBs, relevant medical records, and denial letters or any other written or telephone correspondence.  For payers other than Aetna, CIGNA and Principal, include a copy of the repricing face sheet.

3. Your appeal must include new information.   If the denial is related to a fee schedule error, explain what you believe was in error.  If you believe a CCI edit was incorrectly applied, state this information.  If the payer has a documented payment policy that supports your position, provide this information also.  For example:

  • "Payment was denied for code 76872-59 when submitted with code 76942 on the same date of service. These procedures are allowed together when the modifier 59 is used."
  • "Payment was denied for multiple units of code 88305 submitted on the same date of service. Multiple units are allowed on code 88305."
  • The administration of a vaccine procedure code 90471 was denied stating it was a secondary add-on code without the appropriate primary code being also billed. 90471 is not a secondary add-on code and is not dependent upon a primary code."
  • "CPT code 36556 was paid at 50 percent of the fee schedule allowance, but it is modifier 51 exempt."

4. Be timely.  Once the payer's time limit has passed, a denial will not be reversed.

5. Observe privacy regulations.  If documentation of your appeal includes EOBs from similar claims that were paid differently, be sure to de-identify patient information that is not relevant to the appeal.

If you have followed the payer's appeals process and still not achieved your desired outcome, e-mail Complaints and Appeals for additional assistance.