Drafting A Level I Appeal:  Three Components of a Winning Appeal

Level I appeals need to be submitted timely. Medicare appeals must be filed within 120 days of the claim decision. Most commercial insurers require appeals within 180 days from the denial.

These time constraints force medical providers into situations where the appeal must be filed before all information has been gathered regarding the claim. In particular, the insurance company may not have provided sufficient denial detail to allow providers to draft an informed, detailed response.

AppealLettersOnline.com has a number of appeal letters meant to both initiate the appeal and demand from the insurance carrier a detailed explanation regarding the denial. These templates allow providers to both meet the Level I appeal filing deadline and initiate a review that focuses on full disclosure of denial information.

We recommend that you review your Level I appeal to see if the following three components are addressed:

(1) Level I appeals should demand full disclosure of denial details. Denials can be vague. Even clearly stated denials such as “denied due to lack of medical necessity,”  does not provide you with important information such as the clinical criteria used to assess treatment. Therefore, a Level I appeal should request the specific written limitation, exclusion or internal guideline which applies to the denial. You should also request the clinical criteria used to assess the claim as well as the name and credentials of the reviewer in regard to any decision which required medical assessment.

(2) Level I appeals should demand review by a qualified professional with consideration given to your internal quality care standards. Clinical denials involving application of treatment standards should be reviewed by a medical professional with similar credentials to the treating professional. Further, if your organization uses written, peer reviewed treatment guidelines, explain and provide information about that resource and how it supports the care given. The insurance carrier may be utilizing written standards which were developed with more optimum conditions in mind. Point out any variations in the treatment guidelines and any unique medical factors which might mitigate application of any written standard. In regard to coding denials, demand that the appeal be reviewed by a licensed coder familiar with the specialty coding guidelines applicable to that claim.

(3) Each appeal should identify any potential compliance issue regarding the carrier's legal and/or contractual claim processing obligations in all your appeals. This requires being well educated on both state and federal claim processing requirements and potentially applicable utilization review standards. You should also review the denial for compliance with the carrier’s contractual obligations and negotiate all managed care contracts to include claim processing and appeal review standards which mimic insurance consumer protection laws. Some of the most important protections to consider include disclosure of denial information including clinical criteria used in reaching a decision, peer review of all adverse determinations upon provider request and review of appeals by qualified medical and coding professionals within specified time frames. These are standard legal protections extended to insurance consumers in many states which are not necessarily granted to provider-initiated appeal review. In regards to review of coding appeals, negotiate your managed care contract to include an agreement on a nationally recognized source of bundling edits such as the National Correct Coding edits. Your appeals can then focus on whether the bundling or coding denial complies with this national standard.