APPEALS PROGRAM

For institutions implementing new measures to actively ensure financial solvency, appealing a denial of reimbursement is absolutely necessary. Between the need for physician review and time limits to submit, many over burdened hospital utilization review staffs have refocused productivity with the aid of RTR’s Hospital Appeals Program.

Our staff is referred accounts on a daily basis to appeal denials of reimbursement on utilization and administrative grounds. Upon receiving a referral, the collection of all pertinent hospital records (payer’s denial, explanation of benefits, the UB-04, and the medical record in question) commences.

Appeals of accounts for which reimbursement was denied on utilization grounds are prepared by physicians. A physician will thoroughly review a patient’s medical record to write an appeal that presents the clinical rationale for the patient’s hospitalization. The appeal will focus on the dates for which reimbursement was denied, detailing pertinent information to substantiate that the services rendered were medically necessary and appropriately provided.

All appeals are submitted by certified mail with a return receipt requested. When the specified time for an appeal response has expired, follow-up for a decision on an appeal is commenced immediately thereafter.