Prudent Use Of Appeals

Posted by Ecareindia on August 26th, 2013

Most medical billing companies in the US have a specially-recruited team of professionals to handle claim denials. The reason is that they anticipate claim denials from insurance payers, which has become more frequent these days. When a claim gets denied, the specialized team takes several steps to analyze the cause for denial. Once the problems are sorted out, the claim is resubmitted to the Payer. However, if the same claim gets denied repeatedly for unknown reasons, then a medical insurance billing company can send out what is called an ‘Appeal’ to the Payer. Let’s learn how it can be used prudently for successful reimbursement:

  • An appeal can be filed when claims get denied repeatedly for unexplained reasons by the Payer. Unlisted codes, bundling of codes, and missing modifiers are some issues that result in claim denials during medical claims billing.
  • There are also other reasons for the denial of claims. For instance, if the Healthcare Provider is out of the Payer’s network, then the Payer might show reluctance in reimbursing the Provider by denying claims. 
  • An appeal can be filed only when the reason for claim denials is unknown and after trying out all possible ways to correct and get the claim paid fails. It can also be done when a dispute arises between the Payer and the Provider or medical billing company.
  • Usually, medical insurance billing companies help Providers in sending out reconsideration appeals, which has to be done within a time period of 180 calendar days from the date of denial notice.
  • In case the Payer denies the reconsideration appeal, then a Level 1 appeal can be sent out within 60 calendar days. Sometimes, the Level 1 appeal also gets denied. In such cases, a Level 2 appeal can be filed within 60 calendar days from the date of Level 1 denial notice.
  • Following this process in a diligent manner can help Providers and consequently the medical billing companies get their reimbursements on time. To do so, US medical billing companies must take help from offshore billing companies for prudent use of appeals.


Frequent use of Appeals: Appeals have to be used judiciously for maximum effect.  If a Provider or medical claims billing company resorts to Appeals frequently, then there is a possibility of the Payer blacklisting the Provider and their claims.  The Appeal always has to be used as a last resort when all the other problems with a claim are resolved and still there is a denial which is not properly explained by the Payer.

About e-Care India:

e-Care India is one of the renowned medical billing companies in India that promises the above mentioned benefits with total customer satisfaction. With 13 years of experience in the industry, e-Care’s offshore medical billing delivery centers have been providing end-to-end medical billing services seamlessly to its clients. To know more about e-Care and its services, log on to

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Joined: June 20th, 2011
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