Tips on Navigating the Appeals Process Successfully
By Nora Hansen, CPhT
Patient Billing Representative and Certified Oncology Pharmacy Technician, Illinois Cancer Specialists
This is the first in a series of three Expert Tips articles from Nora Hansen. Read on for Nora’s insights.
Nothing slows down a patient’s treatment plan quite like a denied authorization.
The appeal process can be lengthy and very frustrating.
Here are some helpful pointers on how to navigate the appeals process successfully:
- Read through the denial to understand the reason, as it is usually stated.
- Compile your evidence, otherwise known as the NCCN guidelines or FDA indication if on label. Always submit your most recent chart notes, test results, and any radiology scans to support the appeal. These items are important to help the reviewer to get a full picture of the patient’s condition.
- If the request for treatment doesn’t comply with the plan’s guidelines, a letter of medical necessity is advised, along with any medical journal articles that provide evidence supporting the request. More information is always better.
- Check PubMed.gov for any published articles or citations to include with your appeal. It’s an excellent source and easy to use.
- I always expedite the request as the standard turnaround time for most appeals is 15 days. Check the original denial for the proper channels to apply.
While appeals can be time-consuming and frustrating, following these tips can help reduce the difficulty and help you get the patient approved for treatment sooner.
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