How to Compose an Effective Appeal Letter

Writing an effective appeal letter to an insurance company can significantly, and positively, impact your revenue flow. Once you find that your claim has been denied and you have exhausted any reconsideration rights to dispute the denial reason, it is necessary to respond to the insurance company with a well written and persuasive appeal letter. Implement these steps to craft a successful letter and gain the maximum reimbursement due them. 

A) Components to be included in the letter 

• Header: The list found below is extremely important and needs to be carefully reviewed for accuracy to ensure proper routing and identification of patient demographics that relate to their insurance policy. Any minor discrepancy can result in the rejection of your appeal and thus delay in reimbursement. 

1. Payer Information and Address 
2. Patient Demographics 
3. Date of Service 
4. Member ID 
5. Claim Number 
6. Description of Denied Service including CPT code 

• Body: This is your chance to confidently present the facts referencing payer policies, coding guidelines and state and federal regulations. Present the main points to the addressee while being clear and concise, choosing your words carefully to convey assertiveness, use the power of persuasion but do not “write angry.” Elevate your argument not your tone. Be credible with correct grammar and punctuation. Advocate for the patient when making your argument and make sure the main points directly relate to the denial reason and overall medical necessity. When closing, restate the main points directing them to consider all attachments when making their determination. 

1. Addressee 
2. Intro Paragraph 
3. Argument 
4. Closing Paragraph 

• Closing: Choose a salutation that conveys appreciation. Attention to detail yet again making sure your contact information is accurate and up to date. It is helpful to include the best hours of the day that they can contact you to ensure you are available if they reach out.

1. Salutation 
2. Name 
3. Credentials 
4. Contact Information 

• Attachments: A legible copy of any medical record document that you have referenced in your letter needs to be attached. This will also apply to any copies of code definitions, payer policies, and state and federal regulations. Be sure to organize these logically as they relate to the content of your letter. 

1. H&P, Progress notes, Imaging, Discharge Summary 
2. Operative report 
3. Orders and Consents 
4. CPT code definition 
5. Payer Policies 
6. State and Federal Regulations 

B) Putting it all Together: Consider these factors before sealing the envelope or hitting the upload button. It is important to carefully review the information you have chosen to include. If it is not truly pertinent to the denied claim, remove it. The order you send documents in  is key for the appeal department to understand the story you are creating. Be sure to call or review the payer policy online to have accurate information as to how they accept appeal letters, some of them prefer the submission to be online while others may only provide a specific mailing address. If a case or tracking number is issued, be sure to document it for your records and keep a hard copy for your records. Most importantly, revenue cycle professionals must have a way to track the appeal and follow up to ensure that the appeal was received and the claim was reprocessed for proper reimbursement. A spreadsheet can be a useful tool in managing the life of your appeal letters and claim denial resolution. 

• What to include/remove 
• Order of documentation 
• How to submit? Upload? Fax? Certified Mail? 
• Tracking/Follow up 

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