The Appeal Letter Newsletter - Nov 5, 2014
November 2014 eNewsletter
What Works and What Fails Online For Your Review
Greetings Randall Fuchs,

When appealing denied claims, it is helpful to know what has worked in the past for similar types of appeals. Access to past decisions, however, is not widespread nor easily searched.
However, the following two sites provide synopses on decisions related to higher level (Level II or above) appeals which provide a significant picture of how certain denials are reviewed . . . .
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divider.gif Featured Letters: Duplicate Denials features two appeal letters for duplicate denials. Duplicate denials are of growing concern with healthcare organization due to the upcoming ICD-10 implementation. Some duplicate denials can be tracked back to:
  • Inadequate claim detail   
  • Delayed clinical detail
  • Poor claim submission tracking features
  • Poor payer claim acknowledgment  
Many organizations are using the ICD-10 delay to focus additional efforts on claim processing improvements with an emphasis on lower duplicate denials, corrected claims and submission delays. Now is the time to identify internal claim processing bottlenecks and get the claims submission engine running efficiently.
Online Appeal Decisions Access
Does your organization utilize online healthcare claim review decisions? If so, please let us know the name of the site. We are also very interested in any comments related to how such information is used so that we can pass along tips for better denial management.
For example, the following is a Linked-In exchange regarding using the patient pain level to argue for coverage of emergency care treatment:

Appeal Question: I have been reviewing overturned claim denial data from the California Department of Managed Care. In regards to urgent care denials, the level of pain reported by the patient seems to be a significant determining factor on overturned decisions. Does anyone use this as a marker for selecting denials.
Answer: from Kathie Bender, CPHM, at Next Recovery Source: Absolutely, and the pain level can be supported by elevated BP, pulse and RR (respiratory rate).

Post appeal suggestions on the users forum or email Tammy Tipton at
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