eNewsletter

Successful Strategies for Avoiding "No New Information" Denials

Unfortunately, one of the most frustrating and common denial responses from carriers are the words "Denial upheld. No new information submitted."

A No-New-Info appeal response is a clear signal that your organization may be submitting form letter appeals without making claim-specific customizations to the appeal letter.  Appeal form letters have become routine in the industry and payers can easily spot an appeal which has been auto-generated using claim data alone.  An appeal should provide patient-specific information to support the appeal and the type of information to include depends on the denial...

Log in to read this full article.

AppealLettersOnline.com: Featured Letters

The AppealLettersOnline.com appeal letter collection has a number of appeal letters for demanding the release of the clinical criteria used by the carrier in reaching the denial.  Many denials based on "lack of medical necessity" involve published clinical criteria.  However, clinical criteria may be inapplicable to more complex patients and may also be out-dated for current circumstances.  For that reason, it is important to determine the source of the criteria being applied as well as review a copy of how the criteria reads to determine if it specifically references specific patients population in question in the appeal.

See the topic Medical Necessity and the subtopic State Medical Necessity Terms at AppealLettersOnline.com for a list of state-specific demands for clinical criteria including the following:

• California Request for Clinical Criteria

• Colorado Request for Clinical Criteria

• Florida Request for Clinical Criteria

• New York Request for Clinical Criteria

• Texas Request for Clinical Criteria

You may also use generalized wording to seek specialty-specific clinical criteria such as the following demand:

Please furnish the (SPECIALTY) clinical review criteria used to reach this decision.  This information is necessary to determine if the clinical rationale used in making the coverage decision is consistent with current (SPECIALTY) standards of care developed by practicing specialists in this field of medicine.

It is our position that this treatment is medically necessary and appropriate for this patient’s medical condition.  Further, any medical guideline employed in any aspect of medical decision making must be flexible and allow for deviations from the guideline in order to accommodate the patient’s unique medical needs and challenges.  Therefore, we request the following information which will allow us to assess the appropriate application of the clinical guideline and determine if the referenced guideline is specific to this patient’s needs:

1. Name of the board certified (specialty) reviewer who reviewed this claim and a description of any applicable advanced training or experience this reviewer has related to this type of care;

2. Board certified (specialty) reviewer’s recommendation regarding alternative care;

3. A copy of applicable internal clinical guideline, source of the guideline and the date of development;

4. An outline of the specific records reviewed and a description of any records which would be necessary in order to justify coverage of this treatment;

5. Copies of any peer-reviewed literature, technical assessments or expert medical opinions reviewed by your company in regard to treatment of this nature and its efficacy.

Don’t let denials become a revenue drain.  Access these letters and many more at AppealLettersOnline.com

Did Anyone Check The Law?

Raising Legal Issues in Medical Appeals

Appeal review often involves more than a review of the clinical aspects of a submitted claim.  With the explosion of regulatory requirements related to medical appeals, it is now important to review denials from both a clinical and legal standpoint.

We are currently collecting information regarding the most frequent legal issues which arise with denied claims and how to present an appeal that seeks both a quality clinical and legal compliance review.

Please contact us with any of your tips and/or success stories regarding the following:

• Using ERISA in appeals - success stories wanted.  How did you use ERISA and what types of denials does it work best to resolve?

• Out-of-network appeals - there are a number of new legal cases related to out-of-network appeals.  Let us know if you see any payer changes as a result of these new cases.

• Legalities related to specialty-specific claims under the Mental Health Parity and Addiction Equity Act and Women's Health and Recovery Act.  Does citing these laws work well on your appeals?

• And finally, appeal deadlines.  Appeal deadlines are more standardized since passage of the Patient Protection and Accountability Act but are your payers compliant with the deadlines when processing provider appeals?

Don’t let insurance carrier ignore important legal protections related to claim review.  Subscribe to AppealLettersOnline.com for 1750 appeal letters many of which cite legal information to support the appeal.