There are now a number of processes that can be utilized to appeal a denied claim. It has been the experience of the PRS, LLC. billing service that the most effective process for appealing claims for larger payers is through online submission of the redetermination request for a claim.
Not all payers have this capability, however, those that provide online services such as claims prior authorization, pre-certification, claims analysis and appeals do so to reduce internal costs. As these tools are intended to reduce costs they also afford the practice a more defined process that tends to lead to better results. Online services for redetermination allow one to upload the information required for a formal first level appeal with all information requested which will likely include: the claim, EOB, reason for appeal (use template letter in this document to guide your submission) and supporting documentation (also included in this packet). You should receive immediate confirmation of the submission. We encourage you to note any information provided as proof of filing.
The information provided in the form letter that is included in this packet can be used as a template to accompany a paper redetermination via facsimile or via traditional mail service. Note if you using either mail or facsimile you will need to aggressively follow up with the payer to make sure the information has been received and is being processed by the payer.
Upon review of the redetermination the payer will notify you of coverage and payment decisions. If the denial is upheld, you may be able to file a next level appeal or charge the patient for the service and allow the patient to appeal the denial. These follow up steps for an upheld denial may vary by payer contract.