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1 | Special Edition - Appeals e-book 2008

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The Art of Appealing Index Authors thanks...................................................................................................................... What is an appeal?................................................................................................................. Appeal variables..................................................................................................................... What are the steps I need to take to submit an appeal?........................................................... Step 1 - Determine if an appeal is necessary.............................................................. Step 2 - Determine if you have the right to appeal..................................................... Step 3 - Is the Doctor contracted or not.................................................................... Step 4 - Determine how far you want to take the appeal........................................... Step 5 - Gather your evidence to support the appeal................................................. a) Make a demand for the foundation behind the claim denial.................... b) Research state laws................................................................................. c) Investigate federal laws........................................................................... d) Investigate medical society information.................................................. e) Research the patient benefit manual........................................................ f) Review carrier policies and procedures.................................................... g) Review state resources............................................................................. h) Read carrier provider manuals................................................................ i) Review provider contracts........................................................................ j) Provide documentation of other carrier payments.................................... k) Investigate class action lawsuit settlements............................................. l) Provide proof of insurance company’s past payments............................... m) Review the medical record..................................................................... n) Use the CPT and ICD-9-CM manuals.................................................... Step 6 - Prepare your appeal..................................................................................... a) Show medical necessity............................................................................ b) Use references that support your appeal.................................................. c) Keep your appeal professional................................................................. d) Send your appeal by certified mail/return receipt................................... e) Follow the appeals process to the letter.................................................... f) Follow-up on your appeal........................................................................ g) make a decision on your final step........................................................... Medicare Appeals Process...................................................................................................... First level of appeal - Redetermination.....