Know Your Rights: Making the most out of your appeals

September 09, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

Thanks to California Medical Association (CMA)-sponsored legislation (AB 1455) signed into law in 2000 and the resulting regulations, payors are required to have a fast, fair and cost-effective dispute resolution mechanism (i.e., “appeal process”) to resolve provider disputes. Anytime a payor contests, adjusts or denies a claim, they are required to advise the provider of the availability of the appeal process and instructions for submitting the appeal.

Payors are also required to acknowledge receipt of a written appeal within two working days for electronic appeals or 15 working days for paper appeals. The payor is required to respond to written appeals submitted by providers within 45 working days of receipt, and they must report to the Department of Managed Health Care, on an annual basis, the nature and volume of appeals received [28 C.C.R SS1300.71.38 (e)(f)(k)].

While these requirements provide safeguards for verification of receipt and timely review of your appeal, physicians still face numerous challenges when pursuing the appeal process.  To overcome these challenges and make the most out of your appeals, CMA recommends the following:

  • Clearly state in the subject line and first sentence of your appeal letter that this is an “APPEAL.” Steer clear of the word “inquiry” in your appeal. Use of the word “appeal” leaves no doubt about your intention – to appeal the payment (or non-payment) of the claim – and will ensure the appeal gets to the right department and will be responded to in writing within the required timeframes.

  • Make sure you are sending your written appeal to the correct address. Some payors, such as Blue Shield, have a different P.O. Box for claims vs. appeals. If you send your written appeal to the claims address, it will likely be processed as an “inquiry” and not an appeal, which means you may not receive a written response, let alone the desired outcome of reprocessing of your claim.

  • Clearly state your “ask,” ideally at the beginning and the end of your letter. For example, are you asking that the bundling edits be re-reviewed, are you asking for a medical necessity appeal to be reviewed by a physician of same or like specialty, or are you disputing the payor’s claim that the patient wasn’t eligible? Simply venting about your frustration with how a claim was denied incorrectly or underpaid isn’t enough to communicate why you believe the claim was processed incorrectly or what action you are requesting in your appeal.

  • Look out for the written acknowledgement of receipt of your appeal from the payor within 15 working days of the day you would expect the payor to have received it. If you don’t receive the acknowledgement of receipt, there is likely a problem and a phone call to the payor may be in order.

  • Look out for the payor’s written response to your appeal that should include the pertinent facts and reasons for its determination, which should arrive within 45 working days of receipt of the appeal.

If the payor upholds its decision on the first level of appeal, pursue a second or final level appeal (if available). Review the payor’s first level determination and provide any additional information or relevant details in support of your argument.

For more recommendations on addressing provider appeals, see CMA’s "Know Your Rights: Quick Guide for Appeals," available free to members in CMA's online resource library

Don’t forget that CMA members and their staff can contact CMA’s practice management experts at (888) 401-5911 or economicservices@cmadocs..org for assistance. If you don’t receive the acknowledgement or written response from the payor, or if you feel the dispute process has failed, please give us a call. We are here to help!


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