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Expert Q&A

Please tell me if you have a list of the time frames for different payers re how long they have to answer my appeals to their denials. I have some that I have received no answer for 2 years so officially they are not resolved. Is it the same for every payer? When can I assume they are overturned?

March 27, 2025 · Anna McGraw

Unfortunately, there is not one list with the different time frames that I am aware of.

Here are some ideas that might be of help.

  1. Commercial Insurance: Many commercial insurers have specific timelines for responding to appeals.
    1. Check the individual websites for information.
    2. Contact payer representatives for help.
  2. Medicare: For Medicare, the response time for appeals can vary depending on the level of appeal.
    1. Check on the CMS website: https://www.cms.gov/medicare/appeals-grievances/fee-for-service to start.
  3. Medicaid: Medicaid response times can vary by state. For example, some states require Medicaid managed care organizations to respond to appeals within 30 days.
  4. State Laws: Some states have laws that set specific time frames for payers to respond to appeals.
  5. Provider Agreements: Always check the provider agreements or contracts you have with the payer, as these documents often specify the exact time frames for appeal responses.
    1. If you do not have access to these documents, ask the contracting team for assistance.

Answered by: Karla Hiravi, BSN, RN | Vice President Clinical Resources, AHDAM and PayerWatch

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Expert Q&A

We are seeing an increased number of payor appeals which state “The HBV review performed is a payment integrity review, not a level of care or a medical necessity review, focused on the payment of services documented in the medical record. Facility documentation submitted and reviewed by HBV has identified outpatient services were delivered, and not acute care inpatient services. HBV is not denying the services provided, rather the review is focused on the payment of services documented in the medical record. In accordance with the application of MCG guidelines, HBV has determined that the services delivered are consistent with an outpatient or observation payment.” We have tried outlining the services performed, resources required, how IP level of care were met by the MCG / IQ criteria they outline. They are still being upheld. What else can we do to argue these denials?

Mar 27, 2025