Appealing Claims Denials

Appealing Claims Denials

This section is compiled by Frank M. Painter, D.C.
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By Caitlin Lukacs

Receiving denied claims can be frightening, and appealing them can seem overwhelming, but it’s important to take the time to do it. “Always appeal. Even the smallest amounts,” says Steven Conway, DC, DACBOH, Esq., a member of ACA’s Medicare Committee. “If we don’t, the insurance companies and Medicare contractors will assume that we agree with their decisions and we’ll never be able to move the profession forward.”

Private-Sector Denials

So, you’ve gotten a denied claim and you want to appeal it, but where do you start? “It depends on the type of denial,” says Andrew Slavik, DC, consultant to the ACA’s insurance relations department. “The two main types of denials are administrative and clinical, and they are appealed or fought in different ways,” he continues.

Administrative denials occur when there are mistakes in the paperwork such as an incorrect ID number on the claim or a technical error. “Most of the time you can call to correct an administrative denial,” says Dr. Slavik. “If it was a piece of information or a number that you had on the claim, but it wasn’t keyed in correctly, that can simply be corrected and run back through the system. It’s not technically an appeal, just a re-processing of the claim.”

Clinical denials occur when insurance companies question the medical necessity of a procedure or treatment or label the procedure as investigational or experimental. Another major reason for a clinical denial is the absence of prior authorization. “Many insurance companies are requiring prior authorization for certain treatments, and DCs aren’t aware of this,” explains Dr. Slavik. “If you’ve already sent in a claim, you can’t go back and submit an authorization after the fact.”

With clinical denials, DCs generally have a lot of paperwork to fill out in a specific timeframe in order to submit an appeal. As Dr. Slavik says, “Each state is different, but you typically have 30, 60 or 90 days to appeal.”

According to ACA’s website,, upon receiving a denial, take the following steps:

  1. Read ACA’s coding clarifications to ensure you are coding correctly.

  2. Review your documentation to ensure the procedures billed are supported in the patient health record and compare your documents to the ACA documentation guidelines.

    “Make sure your documentation shows the patient’s progress or clearly explains why there is no progress yet,” says Dr. Slavik. “And record how you’re adapting the treatment plan to facilitate progress in the future.”

  3. If your coding and documentation are in accordance with outlined ACA and Current Procedural Terminology (CPT)® guidelines, use ACA’s template appeal letter for your specific situation.

    Dr. Slavik notes that you should do a bit of research before sending in your appeal letter. “Look for sources that can support your treatment plan,” he says. “If the insurers are saying that what you did was not medically necessary or won’t be covered after two visits, but you can find sources or guidelines that show that the care is not only medically necessary, but that it is beneficial after two visits, include a list of those sources.”

  4. Visit the state insurance regulations page to determine if any of the information from your state insurance regulations supports your appeal.

  5. If you receive no response, follow the insurer’s instructions for a second-level appeal.

  6. If you still don’t receive a response, notify your Department of Insurance and provide it with all correspondence from the insurer.

Resubmitting Claims

According to Dr. Slavik, it is possible to resubmit a claim if you realize something is missing. “If you were billing an evaluation (EM code) with a manipulation (CMT code) on the same date of service, you need to use a modifier—the 25-modifier to be exact—with the manual therapies. If you forget to put that on the claim form, you can send a letter with an explanation and a corrected form,” he says.

Many insurers will deny claims that include an EM and a CMT code on the same day because they believe the CMT code has an evaluation and management component built into it. With the proper documentation, this can be appealed and corrected.

Medicare Denials

Recently, a majority of the Medicare Claims contractors conducted Chiropractic- Specific Probe Reviews, in which nearly 100 percent of Medicare claims are denied, according to Ritch Miller, DC, chairman of ACA’s Medicare Committee. The main reason is that DCs are not sending in records at all. “One Medicare contractor reported that 75 percent of requested records were not sent in, which leads to an automatic 75 percent denial rate,” notes Dr. Miller. Another significant reason for denials is the lack of proper signatures. “Doctors are simply forgetting to sign off on their records,” he says. Arguments about the medical necessity of certain treatments and procedures make up a third reason for Medicare claims denials in the Special Study audits.

“Doctors must make an effort to send in records when requested, even if the request is for just one date of service,” says Dr. Miller.

Another new trend that is popping up is to deny claims that do not have documented mechanisms of injury. “Basically, Medicare is saying that a patient can’t just come in with a headache and expect Medicare to pay for the care of that headache; there needs to be a reason for that headache,” Dr. Miller explains. Some Medicare contractors are even going so far as to say that the injury can’t be incurred during activities of daily living. “For example, say a patient wakes up in the morning with bad neck pain. The statement in the denials says that the claim is denied because sleeping is an activity of daily living and Medicare will not pay for that,” says Dr. Miller.

Appealing Medicare Denials

There are five levels of appeals for Medicare denials, explains Dr. Conway.

  1. Redetermination. Doctors submit proper appeal paperwork within 120 days. This appeal is done by the Medicare contractor that denied the claim in the first place, so virtually every claim is denied again, says Dr. Miller.

  2. Reconsideration. The appeal must be submitted 180 days from the date of receipt of the redetermination. The claim is reviewed by a Qualified Independent Contractor (QIC). Two QICs in the country work solely on Medicare Part B reconsiderations.

  3. Administrative Law Judge (ALJ) Hearing. The time limit for filing the request is 60 days from receipt of the reconsideration notice. The case file is prepared by the QIC and forwarded to the HHS Office of Medicare Hearings and Appeals ALJs are assigned cases by the Centers for Medicare and Medicaid Services (CMS), and they have 90 days to render a decision. DCs have a chance to appeal to a live, impartial person rather than to an insurance carrier.

  4. Medicare Appeals Council (MAC) Review. DCs have 60 days from the date of the ALJ hearing decision/dismissal to file a request to the Department Appeals Board (DAB) for an MAC review.

  5. Federal Court Review. DCs have 60 days after the DAB makes a decision or declines review to file a request for a federal court review.

“We aren’t having much luck getting denials reversed at the first two levels, but we’re seeing significant success in overturning denials at the third level— the ALJ hearing,” says Dr. Miller. “This might be because the case is re viewed by a judge rather than a Medicare contractor and the DC is given an opportunity to explain and defend his decisions.”

ACA is working on creating a national database of appeals, says Dr. Conway. “If you go to a law library and look for ALJ decisions, you’re not likely to find any because they aren’t usually published. This makes it impossible to determine trends or find examples of what has worked in the past,” he adds.

Dr. Conway is asking any DCs who have gone through the appeals process, particularly at the ALJ hearing level, to send their information to ACA. “If we can create a database of information on past ALJ decisions, it will be easier for DCs to successfully appeal denied claims in the future,” he says.

Just as with denials in the private sector, “ACA has great references on its website,” explains Dr. Conway. “Our goal in creating the resources was to get the information out there so DCs know how to fight back,” he continues. “Ideally, we’re hoping to educate DCs so that they’re using the proper paperwork and following the proper procedures to lessen the likelihood of claims denials in the first place.”


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