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Expert Q&A

When completing an Appointment of Representative form for the provider to appeal on behalf of the patient, who should be listed as the representative on the form?

March 27, 2025 · Anna McGraw

Recommended practice is to designate one person at your organization as your representative and have that person’s signature on your appeal letters. You might select your physician advisor or your UM manager. Select someone who is involved and knowledgeable about your appeal methodologies. It’s common to have appeal letters signed by a representative who didn’t author the actual appeal but has oversight of the appeals process at your organization. That single person acts as the representative on the AOR as well as the signatory on the appeal letters.

Related

My hospital system is seeing an increase in denials from a multitude of payers (but mostly Humana and Aetna via third parties) where the payer has performed a clinical validation audit and found “the medical records submitted did not validate I50.00 (Acute on Chronic Diastolic (Congestive) Heart Failure). The member presented to the hospital for TAVR. It was noted the physician documented a diagnosis of acute on chronic diastolic CHF, however there was no evidence of symptoms. The specific criteria for Modified Framingham criteria was not met….” The payers are downgrading the billed DRG from 266 to 267. We are appealing these denials with the full medical record and outlining the physician’s diagnosis from the records; sometimes submitting past cardiology progress notes to support the diagnosis. Can AHDAM provide any additional tips, policies or insight into these denials and how to approach them for payment?
Expert Q&A

My hospital system is seeing an increase in denials from a multitude of payers (but mostly Humana and Aetna via third parties) where the payer has performed a clinical validation audit and found “the medical records submitted did not validate I50.00 (Acute on Chronic Diastolic (Congestive) Heart Failure). The member presented to the hospital for TAVR. It was noted the physician documented a diagnosis of acute on chronic diastolic CHF, however there was no evidence of symptoms. The specific criteria for Modified Framingham criteria was not met….” The payers are downgrading the billed DRG from 266 to 267. We are appealing these denials with the full medical record and outlining the physician’s diagnosis from the records; sometimes submitting past cardiology progress notes to support the diagnosis. Can AHDAM provide any additional tips, policies or insight into these denials and how to approach them for payment?

Mar 27, 2025