Appeals Process and Key Things to Keep in Mind

Knowledge of modern medicare and insurance appeal strategies is vital for the medical billing and coding group. When Medicare claims are denied or a Recovery Audit Contractor (RAC) recognizes a previous Medicare overpayment, physicians may initiate an appeal with their Medicare carrier.

The appeal process usually comes into play when a physician disagrees about his/her health care services. If a physician is refused to pay for the service provided (assuming a physician is reading the article) , you may have the initial healthcare decision reviewed again. In case, you are in the Original Medicare Plan, your appeal rights are on the back of the EOMB ( Explanation of Medicare Benefits) or MSN (Medicare Summary Notice) that is sent to you from the agency that manages bills for Medicare. Moreover, if you're in a Medicare managed care plan, then you can file an appeal in case your plan doesn't pay for the service as claimed or supposed to be paid. It is the responsibility of Medicare managed care plan to inform you in writing about the designated steps of appealing.

The Five Steps to Appeal a Denied Claim:

At Bikham, we employ a dedicated team of professionals who share in-depth knowledge of the steps that should be considered to appeal a denied claim. We have a strategically designed process that helps investigate the factors responsible for a denied claim.

Appeals Process
  • Figure out the Reason - The primary element your billing team ought to do when a claim is denied is to verify the actual reason for the denial by contacting the insurance provider. Very frequently, denials occur because of the error in the codes that do not appropriately explain the reason for non-payment.
  • How to use claim number - Use the claim figure on corrected claims because if you do not do so, then the claim will error out as a copy or a duplicate.
  • Record the data - Record the data about the telephonic call. When you contact an insurance carrier to re-process a claim, record or note the date, the call of the executive you communicate with and a reference number. Having a record of this statistics will make it easier to reference the executive in case you need to speak to the provider more than one times.
  • Set reminders about the follow-ups - Your billing team needs to follow-up on every claim at the least once each month. To ensure that no claims get overlooked or left undone, the team ought to set reminders about when each claim is due for a follow-up.
  • Send an appeal letter - If you feel need to appeal a denial, your letter to the insurance agency should be neat and meticulous to make sure a rapid appeal process. The appeal letter should easily identify the information of the patient, claim number, date of service, member ID and ASC provider number. The letter should be thorough and supporting documentation should be also be attached. Finding the time to provide all the essential details in the first place will save your ASC, the troublesome of sending extra records or having your appeal denied.

There are further five Stages in the Medicare appeal process that may come in handy during the appeal process. We will always try our level best to help you get rid of the headache of this complicated different levels of appeal process and increase your cash flow.

  • First Stage of Appeal: Redetermination by a Medicare carrier, FI (Fiscal Intermediary), or MAC (Medicare Administrative Contractor).
  • Second Stage of Appeal: Reconsideration by a QIC ( Qualified Independent Contractor).
  • Third Stage of Appeal: Hearing by an ALJ (Administrative Law Judge ) in the center of Medicare Hearings & Appeals.
  • Fourth Stage of Appeal: Review by the Medicare Appeals Council.
  • Fifth Stage of Appeal: Juridical Review in Federal District Court.


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