Why You Should Include Payer Coverage Guidelines in Appeal Templates

Denise Wilson | October 28, 2019

Including payer coverage guidelines in your appeal letter templates can increase the efficiency and effectiveness of your appeal writing. Most payers develop and publish specific coverage and payment guidelines for medical and surgical procedures. Published guidelines ensure payment is made only for services that are medically necessary to effectively treat a person in a medically effective but also fiscally responsible way. CMS publishes these payment guidelines as National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Commercial payers often publish their payment guidelines as Clinical Policy Bulletins (CPBs), Medical Policies, or other similar titles. It’s generally easy to find these guidelines on the Internet. CMS has a Medicare Coverage Database (MCD) available at http://www.cms.gov/medicare-coverage-database/. You can find both NCDs and LCDs there. Most commercial payers publish their CPBs in the Provider area of their public websites. You must also consider if your provider entity holds a contract with the payer and whether there are additional coverage policies that may apply.

When reviewing an NCD, LCD, or CPB, pay particular attention to the sections that spell out the following:

  • Coverage Indications
  • Limitations and/or Medical Necessity of the Service
  • Documentation Required for Payment of Services
  • Covered ICD-10, HCPCS, or CPT® Codes
  • Billing Instructions

The guideline may require supporting lab results, radiology reports, therapy records, or a listing of current medications. These reports may be located in the files of another provider. When developing a template for a particular medical or surgical procedure, it’s easy to include the list of medical necessity requirements and required documentation in the template. Place the requirements in the template in such a way that the appeal writer can use them as a checklist of sorts to argue that all required documentation is present in the medical record. In some instances, you can give a reason for why particular documentation is missing. For example, explaining why a patient who was unable to tolerate a specific drug regimen prior to advising him to move ahead with surgery could support the explanation of why the patient did not participate in that drug regimen. Having the guidelines in the template means the appeal writer does not have to research the payment policies or guidelines for surgeries or procedures at the time of writing the appeal. Instead, they can compare those guidelines embedded in the appeal letter to the documentation in the medical record. Even if the denial or the given reason for the pre-payment audit is one specific issue—such as a trial of conservative care before surgery—including all of the payment requirements in the appeal letter template allows the appeal writer to reassure the auditor that all documentation requirements were present in the record. That helps prevent a second denial for a different payment requirement.

The final piece of the appeal is to build the roadmap between payment requirements and the medical record. Make it as easy as possible for the auditor or reviewer to rule in your favor by citing specific page numbers of the medical record for the required documentation. If the appeal writer can point the reviewer to the exact documentation in the medical record that supports the medical necessity of services provided, the reviewer will have a much easier time finding the supporting documentation. Conversely, the reviewer will have a much harder time finding a reason to deny the appeal. Creating a road map can be accomplished in a variety of ways. Still, in its simplest form, a road map is a citation of the name of the document and the page number of the medical record for the documentation referenced in the appeal.