Skip to content
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

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?
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
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.
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.

Mar 27, 2025