1. Review every denial to determine the validity of an appeal. If the denial is valid, do not appeal. However, appeal every case where there is documentation to support original coding.
2. Determine the nature of the denial (e.g. clinical validation and/or coding issue) and seek the relevant clinical and/or coding expertise to write the appeal. Include both clinical and coding expertise as necessary.
3. Restate in the appeal the reason for the denial from the denial letter.
4. Keep the appeal letter concise, factual, and specific to the reason for the denial. Providing additional comment or insight unrelated to the denial reason is distracting and may cause confusion.
5. Include pertinent record excerpts that support the appeal, noting the specific documentation source and date.
6. If complete reports are helpful to support the appeal (e.g. an operative report), make sure such reports are included with the appeal.
7. Include pertinent guidance, such as Official Coding Guidelines, Coding Clinic and CPT Assistant (as applicable), to support the original code assignment.
8. Include the credentials of everyone involved in developing the appeal letter so that the payer is aware of the expertise of the people who are refuting the denial.
9. Include a deadline for a response from the payer (e.g. explicitly state “if no response by dd/mm/yy, we’ll consider the claim upheld and will not pay back any portion of the reimbursement”)
10. Request/require the payer to disclose the expertise (i.e. credentials) of the individual(s) who determined the denial (initially and upon re-review).