eNewsletter: Reimbursement eNewsletter for the healthcare community

ISSUE 69 July 13, 2010






























Appeals Should Clarify Fuzzy Denials
Some appeals succeed, others fail. Why? Unfortunately, many appeal letters fail because of THE CLAIMS ADJUDICATION GREY AREA. . . . Read this article >>
AppealLettersOnline Featured Letters
We've added and updated a number of state-specific letters in the repository. See the following:

  • Alaska Utilization Review Law (new)
  • California Refund/Recoupment Law (new)
  • Kansas Nurse Practitioner (new)
  • Massachusetts Request for Clinical Criteria (new)
  • Montana Request for Clinical Criteria (new)
  • Michigan Request for Clinical Criteria (new)
  • Missouri Request for Clinical Criteria (new)
  • Missouri Chiropractic Benefit Law (new)
  • Missouri Nurse Practitioner (new)
  • Massachusetts Workers Comp Prompt Pay (new)
  • Massachusetts Workers Comp Payment Inquiry (new)
  • Ohio Coordination Law (updated)
  • Massachusetts Non-Participating Payment (updated)
  • Alaska Mental/Nervous and Substance Abuse Law (updated)
  • Kansas Mental/Nervous and Substance Abuse Law (updated)
Access these letters >>
New ERISA Appeal Letters Coming in August
Patient Protection and Affordable Care Act will extend ERISA Appeals Protections. 

The Patient Protection and Affordable Care Act (PPACA) is extending new appeal protections which will make it easier for providers to assist patients with denied medical claims.

The law provides consumers with a way to appeal coverage determinations or claims to their insurance company and establishes an external review process. These changes are effective for health plans beginning on or after September 23, 2010.

The PPACA mandates stricter appeal review and disclosure guidelines which are expected to affect claim denials related to medical necessity, experimental/investigational, emergency care, maximum benefits and usual, reasonable and customary calculations.

The law seeks to simplify the appeal process by providing federal requirements applicable to all plans. Carrier will be required to provide an internal appeal review process in compliance with state appeal review or ERISA regulations and an external review process in compliance with state external review law or the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners (NAIC).

The August newsletter will feature instructions on using PPACA protections in appeals and will provide a number of new letters citing the extended protections.  Be sure to signup as a member so that you have access to this information.