Documentation needed

Here are explanations of the different types of appeal you may make using the Provider Appeal Level I and Level II forms, and the supporting documentation required for each.

Appeal forms we receive without the supporting documentation specified below will be returned unprocessed.

Type of appeal

Appeal documentation required

Administrative appeals

Filing limit

Example: Claim was rejected for receipt after the one-year time limit

Documentation must show proof of timely filing or explain the extenuating circumstance(s) that resulted in a filing delay

High-tech radiology authorization

Example: Claim was rejected because no authorization was given

Documentation must explain why no authorization was obtained.

Reimbursement dispute

Example: Provider questions the contract terms applied to the claim

Documentation must include a detailed explanation of the disputed reimbursement (overpayment or underpayment).

 

Coding appeals

Coding/clinical edits

Example: Provider questions the claim payment based on line-item coding

  • Documentation must include all medical notes relating to the service: Office visit notes, procedural reports, and operative reports.
  • Include references to clinical coding guidelines if applicable
  • If you have revised modifier use, send as a corrected claim.
Denials seeking medical notes

Example: Claim was denied due to lack of supporting documentation for a procedure code, listed or unlisted

Documentation must include all medical notes relating to the service, including procedural reports and operative reports.

Medical appeals

Medical authorization/medical necessity

Example: Claim was denied due to a lack of authorization, lack of medical necessity, or units exceeding the number authorized

  • Documentation must include a written explanation of why you believe the service should be authorized.
  • Documentation must also include medical notes relating to the case.

 

Inpatient denial or carved-out days

Example: Entire inpatient claim or specific carved-out days were denied due to lack of medical necessity orclinical criteria not being met, level of care clinical discrepancy, DRG discrepancy, or readmission within 30 days

  • Documentation must include all procedural or operative reports relating to the disputed denial.
  • Include the clinical rationale that supports the inpatient level of care.