Appeal that Claim
"Sometimes one letter is all it takes," said Jan Faibisoff, MD, an AMA member from Illinois. And he should know. He collected at least $10,000 more in claims by appealing denials with the AMA's "Appeal that Claim" letter templates.
One practice in Chicago recovered $19,000 over 6 months from appealing a single type of underpaid claim.
Within five months of implementing an effective auditing and appeal process, one practice in Chicago was already recovering as much as $100,000 per month.
Taking an active approach to the appeals process
The American Medical Association (AMA) developed the interactive resource "Appeal that claim" to simplify the claim audit and appeals processes for physicians and their practice staff. This interactive resource can help reduce the administrative burden by delivering a step-by-step course of action to appeal an underpaid, delayed or inappropriately denied claim.
"Prepare that claim" and "Follow that claim" were also developed to help physicians and their practice staff to review the efficiency of their current internal claims management process, as well as understand the payer’s role in the claims process. These resources contain sample forms and policies that can be adapted to fit the specific needs of a physician practice.
Learn more on how to appeal claims from the resources below.
Access toolkits to help you effectively use key Health Insurance Portability and Accountability Act (HIPAA) electronic health care transactions in your practice, including eligibility, claim status, electronic funds transfer and prior authorization. Don't wait—start experiencing the savings!
With this free tool, you can look up the reasons health insurers reported for denying claims on the electronic remittance advices (ERAs) you receive. Then, you can determine the best steps for your practice to reverse the denial. The tool even helps you get started with recommended workflows for top denials and provides numerous template appeal letters that AMA members can easily modify to use in their practices.
View sample claims management letters for the physician practice. As a benefit of membership, AMA members can download these sample letters as Word files to modify and customize in their practices. For more information on these letters, or to access a majority of them in PDF format, consult Step 5 in the resource "Appeal that claim."
AMA members can also access the National Managed Care Contract Database, where they can look up state laws and regulations to copy and paste into their appeal letters.
Authorization & eligibility
Contractual obligation
- Claims underpayment letter
- Letter to health insurer regarding late payment
- Letter to state insurance commissioner or other entity that regulates various health insurers regarding late payment
- Letter to patient's employer or health plan sponsor regarding late payment
- Letter to health insurer regarding late payment of claims in violation of practice's contract
- PPO discount taken when a contract does not exist
Medical necessity
- Letter to health insurer regarding late payment
- Medical necessity denial letter—Option A
- Medical necessity denial letter—Option B
- Letter to patient to notify of appeal
Payer-applied edits
- Claims underpayment letter
- Lack of recognition of CPT® modifier 25 letter
- Lack of recognition of CPT® modifier 59 letter
- Inappropriate E/M downcoding
- Insurers not accepting new CPT® code sets appeal letter
Prompt Payment
- Letter to health insurer regarding late payment
- Letter to state insurance commissioner or other entity that regulates various health insurers regarding late payment
- Letter to patient's employer or health plan sponsor regarding late payment
- Letter to health insurer regarding late payment of claims in violation of practice's contract
- Claims underpayment letter
- Timely filing letter
General
- Generic appeal letter
- Inadvertent coding error by physician practice letter
- Letter to health insurer or other payer regarding use of an unapproved method of payment for services
- Letter for request for contracted fee schedule
- Letter notifying insurers of overpayment
- Letter indicating payment to patient and disclaiming further refund obligation
Learn how to select a practice management system that will reduce your time spent on manual administrative tasks that occur throughout the claims revenue cycle and replace them with automated solutions.
