Supporting documentation for appeals
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
- See claim filing requirements in this Manual
|
| High-tech radiology authorization |
|
| 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).
- See over-payment instructions in this Manual
|
| Coding appeals |
| Coding/clinical edits |
|
| 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 |
|
| Benefit exceptions for non-covered services or drugs covered under the medical benefit |
- Example: Claim was denied with a non-covered service code.
- Documentation must include a written explanation of why you believe the service should be covered.
|
| Corrected diagnosis |
- Example: Claim was submitted with an incorrect diagnosis code.
- Documentation must include all medical notes relating to the service: Office visit notes, procedural reports, and/or operative reports.
- Submit a corrected claim with the corrected diagnosis code.
- See "Correcting claims" in this Manual
|
| Inpatient denial or carved-out days |
- Example: Entire inpatient claim or specific carved-out days were denied due to lack of medical necessity or clinical 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.
|
