For clinicians' offices: supporting a patient's appeal

This page is for doctors and office staff. A patient who has been denied usually needs three things from you: the clinical reasons, put in writing; a quick call to the plan’s doctor; and the records. Do them early, and tell the patient what you filed so that nothing is missed.

What this means

You can help at three points. Before a formal appeal, you can ask for a peer-to-peer call, a short phone conversation between you and a doctor at the plan. Some plans offer it, and Connecticut’s state health care advocate notes that it is available there. During the appeal, you can send a letter of medical necessity, the records and the clinical evidence. If waiting could harm the patient, you can certify that the claim is urgent.

The patient’s appeal and yours can be separate. A provider may appeal under its own contract with the plan, and the patient may appeal under the patient’s plan rights. The deadlines can differ. Unless the plan confirms in writing that one counts for the other, the patient should protect their own.

What to do

1. Get the facts from the patient (their step). Ask for a copy of the denial notice, the claim or reference number, the member number and the date on the notice. The notice sets the patient’s deadline, so write it down.
2. Decide urgency now (your office’s step). If waiting for a standard decision could seriously jeopardize the patient’s life, health or ability to regain maximum function, or would cause severe pain that cannot be managed without the care, certify the claim as urgent. Use the urgency certification letter and see expedited appeals.
3. Ask for the peer-to-peer call (your step). Use the call script and prepare the one-page peer-to-peer brief. Ask how many days remain, and ask for the reviewer’s specialty. See the peer-to-peer call.
4. Write the clinical letter (your step). Choose the letter that fits: medical necessity, step therapy exception, off-label use or out-of-network necessity. State the diagnosis, the history, what has been tried, why the denied service is needed and what is likely without it. See what makes a letter strong.
5. Send the records quickly. The Health Insurance Portability and Accountability Act (HIPAA) gives patients 30 days, plus one possible 30-day extension, to get their records. That is too slow for most appeals, so send what the appeal needs straight to the plan or to the patient.
6. Say who files what. Tell the patient whether you are appealing, through which route and by what date. Give them a copy. See patient appeal and provider appeal.
7. Collect the patient’s written permission if you will act for them (their step). Use the plan’s form or the authorized representative designation. See acting for someone else.
8. Ask your billing office to hold the account. The Patient Advocate Foundation advises asking providers to hold the bill during an appeal. A hold is practice, not a right. See the bill while you appeal.
9. Follow up and record it. Note each call, the person and the date. The appeal tracker helps.

What the plan may say, and what to say back

“We cannot discuss this case with you.” I am the treating physician. Please tell me what authorization you need from the patient, and send the form today.

“A peer-to-peer is not available for this denial.” Then please tell me in writing how I can submit the clinical reasons, and the deadline for doing so.

“This is a standard request.” I am certifying that waiting could seriously jeopardize the patient’s health. Please treat it as urgent and confirm the decision date.

The rule

If a physician who knows the patient’s condition says a claim is urgent, a group health plan must treat it as urgent, and non-grandfathered plans and insurers “shall defer” to the attending provider’s determination. Urgent claims and urgent appeals must each be decided as soon as possible and no later than 72 hours. See Code of Federal Regulations (CFR), title 29, section 2560.503-1(m)(1) and 29 CFR 2590.715-2719(b)(2)(ii)(B).

Watch for

• Medicare Advantage. The member, a representative or the treating physician (after telling the member) can ask for a reconsideration. The plan must expedite when the member’s physician says waiting could seriously jeopardize life, health or ability to regain function.
• Medicare drug plans. For an exception, the prescriber must give a supporting statement, and the decision clock starts when the plan receives it. If no statement arrives within 14 calendar days, the plan decides within 72 hours (24 if expedited) after that period ends.
• Medicaid managed care. A provider may file the plan appeal for the enrollee only with the enrollee’s written consent and if state law allows. Providers cannot request continued benefits for the enrollee.
• TRICARE. A provider who does not participate on the claim is not a party and cannot appeal. The beneficiary can.
• Do not invent facts. The letters ask for clinical statements. Fill them in from the chart.
• A regulator may help you too. Washington’s insurance commissioner, for example, publishes a page for providers on helping patients with a denial. Check your state’s insurance department.

What next

• Patient appeal and provider appeal: run both: how to avoid crossed wires with the patient.
• Ask your doctor for a letter: the patient’s side of the same request, useful to share.
• Help someone else with their denial: all the pages on this topic.