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Expert Q&A

Our organization gets late notification denials related to insurance information not being provided at time of admission. Our company makes an attempt to check coverage, but when unsuccessful, we receive the denial for no auth due to late notification. Our leadership wants these appealed and I struggle with an approach to write these appeals. I usually explain that we have no prior insurance information in our EMR, our facility has attempted to check coverage via Waystar or Relay, and that the member did not present insurance information. Is these any other suggestions/ ideas to use for these denials? Thank you.

March 27, 2025 · Anna McGraw

You are on the right track to appeal with the explanation of why the correct insurance was not identified at the time of admission. Most payers are accepting of a request for a ‘retro’ authorization in these instances as long as it’s happens occasionally and not on a regular basis.

Answered by: Denise Wilson MS, RN, RRT | Senior Vice President Intersect Healthcare + AppealMasters President, AHDAM

Related

Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?
Expert Q&A

Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?

Mar 27, 2025