How to Write an Appeal
You may find that an effective appeal letter will often be all that is needed to reverse a claim denial or underpayment. Prior to writing an appeal letter, make sure you examine the EOB, also known as the Remittance Advice Notice, and the initial claim in detail.
The Appeal Letter
Be sure to reference all key elements in your letter and include documentation supporting your appeal as attachments. Documentation might include the following: approved prescribing information (PI), copies of the EOB or remittance notice in question, articles from peer-reviewed medical journals,
relevant peer-reviewed literature, payer coverage policies, fee schedules, medical records, nurses’ notes, plan of treatment, consultation reports, and/or progress notes.
Make certain that the claim is reviewed by a person with strong medical knowledge. You can request that a claim be sent to the payer’s Medical Review department or Medical Director.
In 30 days, follow up on all appeal letters with a telephone call to check on the status of the appeal.
Elements to Include in an Appeal Letter
1. Opening Paragraph: Inform the payer that you are appealing a denial or underpayment. List the payer’s reason for the denial as indicated on the EOB. Or, if you are appealing an underpayment, provide the amount that your office charged, the payer’s allowable, and the amount actually paid. When available, attach a copy of the payer’s fee schedule for the drug or service in dispute.
2. Patient History and Treatment Rationale: In the second paragraph, describe the patient’s condition and the treatment. Explain why the drug was prescribed, including outcomes from the treatment. In addition, you may reference outcomes of other patients with similar conditions who
received the same treatment.
3. Documentation: Appropriate documentation can help support and win appeals.
Examples of appropriate documentation include:
Medical history
> Office notes and progress reports
> Hospital notes
> Operative reports
> Consultation reports
> Referrals
> Documentation of severity or acute onset
> Test results
> X-ray reports
> Plan of treatment
> Physicians’ orders and nurses’ notes
> Copies of communications between provider and patient/beneficiary, hospital, carrier,
laboratory, etc
> Compendia monographs (USP-DI/AHFS) and peer-reviewed literature supporting product’s use
> Documentation that your appeal is being filed within the appropriate time limit (6 months for Medicare claims)
4. Cost-Savings: Payers like to know that they are not only approving payment for quality and medically necessary services, but also that those services are cost-effective. Let the payer know that the consequences of allowing the patient’s condition to advance could possibly require more costly treatment and hospitalization, which could be avoided with the physician-specified treatment.
5. Conclusion: Inform the payer that this information supports your professional opinion and is cost-effective; that they should cover the denied charges or adjust the amount reimbursed.
6. Copy Others: It may also be a good idea to copy others on the appeal letter. You may want to copy the Medical Director, patient, CAC member, local oncology society administrator, ASCO, union representative, local legislator, insurance commissioner, etc.
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