Your right to appeal a denied claim was expanded under the Affordable Care Act. You can maximize the chances that your appeal will be successful by following these tips:
1. Review your EOB - Before you can fight a denied claim, you need to understand why it was denied. Carefully review your Explanation of Benefit (EOB). Check the message or reason codes at the bottom of the EOB. Sometimes your claim was denied only because of a dataentry error like a misspelled name, insurance ID number, or the wrong date of service. Review your claim for errors. If you find a simple error call the payer for a phone review and ask if they can correct the claim for you. If it was an error on the part of your provider, ask them to correct the problem and resubmit the claim. Be sure to mark in Box 19 "Resubmitted claim" or the payer may assume it is a duplicate claim.
2. Review your data - Make sure you have all the facts to show that the services were medically necessary. Referrals, prescriptions and any relevant information should be easily accessible before processing the appeal.