Templated Letters for Appealing Denied Claims
The ACEP Reimbursement Committee and the Coding and Nomenclature Advisory Committee, together have identified the most common reasons that payers inappropriately deny ED claims. A series of templated letters has been prepared to assist you in appealing these claims with your local payers. You may choose a letter based on the nature of the denial you are experiencing, and if it exactly describes the inappropriate denial simply complete the blanks with the names of the payer in question, and submit your appeal. You might also consider referencing pertinent historical and current issues in your state, (for instance you might not be experiencing similar denials with other local, private, or governmental payers). These sample letter templates provide guidance for communicating with a payer provided that appropriate patient health information release requirements have been satisfied pursuant to state and federal law.
Historically, it has been helpful to copy your state insurance commissioner and your state representatives on these appeal letters. However, sending a copy of the letter to anyone other than the patient (e.g., copying your state Insurance Commissioner, a legislator, regulator, or other party) may trigger federal or state patient health information release regulations and so attorney guidance is strongly advised. The American College of Emergency Physicians does not provide legal advice and so does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of this information and recommends consulting legal counsel experienced in this area of the law.
Please contact the ACEP Reimbursement Department, (firstname.lastname@example.org or 800-798-1822 extension 3232), with any questions you may have.
Attn: Provider Appeals Department Address City, State, ZIP Code
Re: Denial or downcoding E/M levels based on ICD-10 diagnosis codes
Health Plan ID Number: