October 13, 2016

Clinical Customizations Win Appeals

First in our "How I Won My Appeal" Series

Medical billing professionals work for hours developing effective appeal letters. However, often, the success stories which result from this effort go untold.  At Appeal Solutions, we love to hear your appeal success stories and now plan to pass them along in an ongoing "How I Won My Appeal" series.

As follows is a successful appeal scenario provided by Christine Henderson, RN, of Scituate, MA.  Henderson successfully strengthens her appeal letter templates by adding clinical customizations pertinent to the patient's highly specific treatment plan. These arguments are often persuasive in getting payers to apply more flexibility to treatment reimbursement guidelines. . . . . Keep reading this article. Featured Letters

The appeal letter collection has a number of appeal letters for appealing level-of-care denials.  Be sure to review our letters under Case Management for appeals templates to use for concurrent level of care appeals. Further, the following letters are available for appealing Observation Level of Care denials and can also be customized for inpatient appeal review:

  • Cardiology Peer Review of Chest Pain
  • Neurology Peer Review of Headache
  • Pulmonary Review of Asthma
  • Request for Clinical Criteria for Observation
  • Request for Coding Criteria - Observation

Access these resources and many more at

Two Appeals Are Better Than One: Helping Your Patients Submit Winning Appeals

Are you involved in proactive patient advocacy efforts seeking to assist patients better develope a strong voice in care decisions?  Do those patients need more information on how to effectively appeal denied claims?

Tammy Tipton, President of Appeal Solutions, enjoys motivating Patient Advocacy Groups to proactively address payer barriers to treatment.  Her presentation, Two Appeals Are Better Than One: Patient Engagement in the Appeals Process, covers how medical professionals and patient advocates can effectively work together to ensure payers are following best practices in care management.

Payer communication are extremely important in patient advocacy efforts. Tipton designs each presentation to cover a few basic communication tools for patients to use to initiate insurance inquiries and appeal denials.  However, patients require basic training regarding consumer protections and will be much more successful when communication tools are explained in the context of specific payer environments. During her presentation, Tipton details patient advocacy appeal steps designed to create a partnership between patient and provider and ensure higher quality payer decision.

The presentation includes customized appeal material designed specifically for each advocacy group. However, most presentations include the following basic appeal letters, depending on the patient group needs:

  • Stalled Claim - Patient Request for Prompt Payment
  • Patient Request for Eligibility Denial Clarification
  • Lack of Medical Necessity - Patient Precertification Appeal
  • Lack of Medical Necessity - Patient Denied Claim Appeal
  • Type of Provider Patient Appeal
  • Emergency Care - Patient Lack of Precertification Denial
  • Patient Experimental/Investigation Appeal
  • Patient Maximum Benefits Reached Appeal
  • Patient Coding Appeal
  • Patient Refund/Recoupment Appeal

Contact Tammy Tipton if you would like to schedule an appearance at your patient advocacy group or to recommend a group which might be interested.  Tipton can be reached at or 888-399-4925 for presentation pricing information.


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