Did you know: The keyword in any appeal is...

August 30, 2013

Thanks to California Medical Association (CMA) sponsored legislation (AB 1455) and the resulting regulations, payors are required to establish 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. They are also required to respond to written appeals submitted by providers within 45 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 §1300.71.38 (e)(f)(k)].

But is your appeal really being processed as an “appeal,” or is it being filed as an “inquiry,” not subject to the reporting and written response timeframes required in California law?

To ensure your appeal is treated by the payor as an actual “appeal,” CMA recommends the following:

  • Clearly state in the subject line and first sentence of your 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.
  • 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. The Blue Shield appeals address in the 2013 Provider Manual is:

Blue Shield of California
P.O. Box 272620
Chico, CA 95927-2620

If you send your written appeal to the claims address, it will most certainly 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 underpaid or denied isn’t enough to communicate why you believe the claim was processed incorrectly.
  • Look out for your written acknowledgment of receipt of your appeal from the payor within 15 working days of the day you would expect the payor to have received your appeal. If you don’t receive the acknowledgment 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.

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


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