The Appeal Letter

ISSUE 27 September 17, 2004

	Appeals - When "Exclusions & Limitations Apply" Isn't Good Enough Time and time again, insurance carriers try to get by with the simplest of explanations: "Exclusions and limitations apply'. Refusing to accept canned denial information will be the subject of an upcoming audio teleconference conducted by Tammy Tipton, President of Appeal Solutions. "The appeals process is about facts and if you aren't getting facts when you appeal, join us on Oct. 14 to find out how to get more detailed appeal responses from insurance carriers," Tipton said. The 90-minute audio conference will feature information on asserting your rights when insurers provide canned denials. Further, Tipton will discuss what laws apply to appeal review and how to use them in your favor to obtain such pertinent details as the credentials of the reviewer and the documentation in the claim file or policy which supports the denial. A number of Level II appeal letters written by Appeal Solutions will be presented and discussed at length. Appeal Solutions is adding a number of Level II appeals to the AppealLettersOnline database to assist members with ensuring that the denial is looked at by different personnel at different levels with in the insurance company. "It frustrates me to think that there are denied claims out there that are dropped after an initial appeal just because the provider didn't get a good appeal response and did not have the resources to continue the appeal," said Tipton. The live audio conference will be held Thursday Oct. 14th at 11 a.m. CST. Cost is $197 per dial in line. Purchase one line and train your whole office staff on appeals. Click here for details... or call 888-399-4925.
	Featured Appeal Letters The AppealLettersOnline.com Repository has numerous state-specific letters to assist with Lack of Timely Filing denials. These letters directly quote state requirements regarding timely filing if any exist. There is also a letter which assists providers with submitted Proof of Timely Filing for the carrier's consideration in situations where the initial claim was timely filed but not received by the insurance carrier due to "address change, system failure or clerical error.".....sign up for access to the appeal letter repository
	New Letter to Assist With Silent PPO Appeals We have a number of physician clients who are reporting problems with incorrect payment which appear to be related to silent PPOs. We have drafted an appeal letter to assist medical practices with these appeals. See the new letter under the category "Benefit Reductions," subcategory "Miscellaneous," titled, Silent PPO.
	Specialty Highlight: The AppealLettersOnline user forum recently featured a question from a rehabilitation provider in Texas regarding a worker's compensation carrier's refusal to recognize use of modifier -59. A customized letter was provided in our response which cites the portion of the Texas Worker's Compensation Act which sanctions the use of modifiers. Members who have experience utilizing -59 on TWCC claims are welcome to add comments on their own first hand experience.