April 18, 2016

ICD-10: Key Performance Indicators To Monitor

You feel pretty good about your ICD-10 implementation. Clean claims are getting filed daily and payments are rolling in. However, are you measuring and monitoring your ICD-10 impact or just keeping your fingers crossed? CMS is encouraging practices to be looking at several performance measures to make sure that any impact is quickly identified and remediated. . . . .

Keep reading this article. Coding Appeals

Payers do not readily provide detailed information about coding edits and many coding appeals will require a Level II or higher appeal. High-level appeal reviewers are likely aware of disclosure laws which may require detailed explanations of how coding edits apply to specific claim scenarios. Therefore, make sure that any coding appeal makes a clear demand for disclosure of the published coding criteria used to assess the claim. Consider the following letters for your coding appeals:

Under the Topic: Specialty Care Appeal Review select your specialty area and review the letters titled Request for Coding Credentials and Request for Coding Criteria.

Under the Topic: Basic Appeal Letters Level I and II select Coding for a more general Level 1 Coding appeal letter and a Level II Coding appeal letter.

Under the Topic: Benefit Reductions select Miscellaneous for a number of appeal letters related to coding inlcuding Bundling, Global Services, Level of Difficulty modifier, Multiple Procedures Reductions, Payment not in compliance with CCI edits and much more.

Access these resources and many more at

Appeal Success Strategies For Pharmaceutical Claims

We are currently updating our specialty-specific appeal letters to include Pharmaceutical Appeal Letters. We are developing 10 - 15 appeal letters specific to appealing denied medication. These appeal letters demand the clinical criteria for denial of a recommended medication. Please see the example below of our Pharmaceutical Appeal Letter for Oncology. Further, we are offering special pricing on inhouse denial management training for any organization interested in indepth staff training on pharmaceutical appeals. During the month of May, your organization can secure our 4-hour denial management training for $1,200 plus travel expenses. The training includes a customized presentation on denial avoidance and appeals specific to your organization. Contact Tammy Tipton at for more information.

Pharmaceutical Appeal Letter For Oncology Medication Denial

Dear Appeals Reviewer,

It is our understanding that the medication (insert name) was denied pursuant to medical necessity or other pharmaceutical coverage limitations. The explanation of benefits did not give adequate information to establish the accuracy of this decision. Therefore, please provide the following information to support this adverse determination.

Please furnish the pharmaceutical 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 oncology pharmaceutical standards of care developed by practicing specialists in this field of medicine.

It is our position that this medication is medically necessary and appropriate for this patient's diagnosis of (insert diagnoses). Further, any pharmaceutical coverage guideline employed in any aspect of medical decision making must be flexible and allow for deviations from the guideline in order to accommodate this patient's unique medical needs and challenges which includes (insert description of needs/challenges/clinical rationale for medication). As the recommended course of treatment provides the safest most effective treatment, we request the following information which will allow us to assess the appropriate application of your clinical guideline and determine if the referenced guideline is specific to this patient's pharmaceutical needs:

1. Name of the board certified oncologist who reviewed this claim and a description of any applicable advanced pharmaceutical training or experience this reviewer has related to this type of care;
2. Board certified oncologist's recommendation regarding alternative pharmaceutical treatment;
3. A copy of applicable internal pharmaceutical 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 medication;
5. Copies of any peer-reviewed literature, technical assessments or expert medical opinions reviewed by your company in regard to this medication's efficacy;

It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non-disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination. Therefore, we appreciate your prompt, detailed response to this request.


Closing Text,

Additional Customization Suggestions:

Attach Medical Records

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