Appeals

Correctly filing an appeal will give you the best chance at an expeditious and successful appeal with a well thought out determination. This page will help you learn how to file an appeal by payer type.

We are happy to help you with appeals for any payer. Please contact us at PayerPolicy@NMDP.org if you need assistance working on an appeal. We have several template appeal letters available for your use and can work with you to help complete your appeal.  

Medicare Appeals

You can appeal on behalf of a transplant patient if you disagree with a coverage or payment decision made by Medicare, your patient’s Medicare health plan, or your patient’s Medicare Prescription Drug Plan.
In order to file an appeal, you must first determine the type of coverage he or she has. The process is different depending on the type of Medicare plan the patient has:

  • Standard Medicare
  • Medicare Advantage plan (Medicare Part C)

Standard Medicare Appeals

Standard Medicare plans do not support a prior authorization process for medical procedures, which means you won't know for sure if the procedure is covered until after the care has been delivered. The Medicare NCD for Stem Cell Transplantation (CMS.gov) is the best way to determine what is covered for your Standard Medicare patients.

If coverage for a transplant is denied, file an appeal of a claim denial.

Appeal Levels

There are five levels of appeals for Standard Medicare. If you have a denied claim, do not give up after one or two levels of appeal. Ensure that all of your appeals go through all levels necessary

Medicare Advantage Plan Appeals

Medicare Advantage plans often require prior authorization, and these plans have a standard 14-day period in which to make a coverage authorization decision. If you believe your patient’s health could be seriously harmed by waiting 14 days, ask the plan for a fast decision (within 72 hours).

If you disagree with your plan’s initial authorization decision, you can file an appeal. Proceeding to transplant without knowing if such an appeal will be successful is financially risky for your institution.

Appeal Levels

There are five levels of appeals for pre-service denials in Medicare Advantage plans. If you disagree with the decision made at any level of the process, you can appeal to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal. If you do not receive a decision within the timeframe identified by Medicare for each level, you can submit your appeal to the next level.   

Resources

Medicaid Appeals

Every state’s Medicaid program is different, but each state must follow a base set of federal Medicaid rules for appeals of medical decisions, including fair hearings when services have been denied, whether during the prior authorization process or after services have been rendered.  

Per federal rules when a Medicaid denial is issued, the notice must include the following information:

  • A clear & understandable statement of the proposed action and the reasons for it
  • An explanation of your right to, and how to get a county conference and a state hearing
  • An explanation of how you can get a “stay put” on your services by timely asking for a hearing
  • The applicable regulations
  • A telephone number to call about free legal services

If you were denied a new service or treatment, the benefit won't be paid for until you receive an approval. For instance, a recipient who gets a notice that Medicaid will not pay for a transplant will not be entitled to "aid paid pending" and will need to win their appeal before they can get the transplant.

Seek a Fair Hearing Right Away

You and your patient should seek a State Fair Hearing as soon as you have any issue with a Medicaid request or denials of services. Often it takes a few weeks to a month to have the Fair Hearing. The State must provide a Fair Hearing and make its decision within 90 days of the date you asked for a hearing. If the patient is in urgent need of transplant, and can't wait the standard 90 days for a Fair Hearing, he/she should ask for an expedited Fair Hearing. The State Fair Hearing Agency should be able to schedule an expedited Fair Hearing right away. 

File an Appeal with the Plan

You should file an appeal with the plan as soon as you receive a denial.  

The plan must reconsider its decision if they did not talk with the doctor who is asking for the transplant for your patient. If you feel a decision was made without discussing the case with your patient’s physician, you have the right to ask for a reconsideration, and a new decision must be made within one business day.

Tips for Medicaid Appeals 

  • Appeal by the deadline: When you receive a denial, the denial notification must tell you how to file an appeal. When looking at the instructions on how to appeal, the appeal deadline is one of the most important pieces of information on your appeal notice. You must request your appeal within the deadline, or you will be required to justify a late appeal. States have different deadlines, but the deadline will be no more than 90 days from the date the denial notice was mailed (and may be less).

  • Appeal to the plan and the state: Many times you can file your appeal with your plan first, but you should also file an appeal with your state Medicaid agency before your appeal deadline runs out. If the appeal with the health plan is upheld, you want to still be able to appeal to the state.

  • Follow the appeal format requested by the state: Some states require that you request your appeal in writing, while in some states you can request an appeal orally.

  • Submit a written statement of patient authorization: If you file an appeal on behalf of a patient, make sure to submit a written statement, signed by the patient, their parent if under age, or guardian if one is assigned, telling the Bureau of State Hearings that you have been given authority to represent your patient. Learn more and understand when this may not apply (DisabilityRightsOhio.org).

  • Provide comprehensive supporting data: Always submit as much information to support your position as you can. The fastest way to get a decision is to submit all necessary information the first time.

Commercial Appeals

Commercial payers have historically offered several levels of appeal. Now, as a result of the affordable care act (ACA) the appeals process is more standardized, offering two levels of appeals: the first level is an internal appeal and second is an external appeal with a binding decision.

Patients (or your center on behalf of the patient) also have a right to move directly to an urgent/expedited appeal if waiting for the appeal would jeopardize their life, health, or ability to attain, maintain, or regain maximum function. An expedited appeal goes to an external third-party review organization, and the decision is binding. If the patient's health warrants, seek an expedited appeal and also file both an internal and external appeal at the same time.

How to Submit an Appeal

Be sure you always follow the exact appeal instructions on the denial letter. While the ACA standardized the Appeals requirements and rules for most plans, some older plans vary state to state and by plan type.   

Before You Submit an Appeal

  • Determine the urgency of the appeal: If you feel that waiting for the appeal decision would jeopardize your patient’s life, health, or your patient's ability to attain, maintain, or regain maximum function you can request an expedited appeal (sometimes called an urgent or fast appeal).

  • Find out who can submit the appeal, you or the patient: Most times you can file an appeal on behalf of your patient, but check to make sure your patient's plan permits this. If the plan allows you to file on the patient's behalf, always submit an authorization of representation form. Sometimes a plan will have a form in the provider tools/forms on their website. If you are not allowed to submit an appeal on your patient’s behalf, your transplant center physician should include a letter of support with your patient’s appeal. You can help your patient file the appeal, or the patient can get help by contacting their state’s consumer assistance department. Consumer Assistance - Help Patients Filing Appeal (CMS.gov).

  • Have your Medical Director call the payer: If your center believes the requested transplant should have been approved, have your medical director call the number listed on the denial letter and ask to speak with the medical director who performs transplant case reviews. Ensure that your medical director has everything needed to be prepared for this call.  

Tips for Submitting an Appeal

Below are tips on submitting an appeal letter. You can also use this appeals checklist (PDF) to be sure that you have all the information that plan will need to process your appeal.  

  • Make sure you send your appeal to the right place: In the appeal instructions in the denial letter you will find information about where to send your appeal. Always use the mailing address, fax, or email listed on the denial letter when submitting your appeal. If you are filing an urgent appeal, always call the plan to find out the quickest way to submit the appeal.

  • Follow any payer-specific appeal requirements: Know the payer, the particular plan and coverage for each denial, then make sure you know how many levels of appeal you have for that specific plan and any rules you must follow (whether you can appeal on behalf of the patient with written consent from the patient, or if the patient must appeal for themselves, etc.). If you aren’t sure if you can appeal on behalf of the patient always submit a completed representation authorization form.

  • Specify the service for which you are seeking coverage and whether this appeal is urgent: Clearly indicate the service that you are asking to get coverage for (i.e. are you using cells for myeloablative or non-myeloablative HCT). Specify in your documentation if this is a standard or urgent appeal. If the appeal is urgent indicate clearly why waiting longer would jeopardize the patient's life, health, or ability to attain, maintain, or regain maximum function.

  • Provide comprehensive supporting data: Always submit as much information to support your position as is necessary. If the payer doesn’t have enough information the appeal may be delayed and timelines can legally be extended (sometimes as much as 30 or 60 days). The fastest way to get a decision is to submit all necessary information the first time.

  • Clearly dispute the specific denial reason with evidence: The denial letter must include the specific reason for the denial and any criteria used in making the decision. In your appeal, include the specific denial language you received in the letter, including the criteria and if possible, provide point by point evidence to refute the denial reasons. 

Appeals for Services Already Provided

If you receive a denial for a transplant that has already occurred, involve the right people from your organization to work with the payer to negotiate the case. Transplants centers handle these issues in different areas of their facility. You may need to engage your contracting department, your administrator, and/or your financial coordinator. You also may need to include your center's medical director if the denial can’t be easily resolved.

If the Original Denial is Upheld

If the original denial is upheld, the decision letter should include information on how to contact the medical director at the plan, as well as to how to file the appeal. It is a good idea for the treating provider to call the plan and ask to speak with the Medical Director or reviewer who made the decision.

Make sure you document somewhere in the record how many levels of appeal are available for the patient’s specific plan or read every denial letter and continue to follow directions for the next appeal level.  Continue to appeal to the highest possible level. Some plans have an in person committee that patients and families can attend in person to plead their case (most cases get approved here).

Track Payer Case Decisions

In order for your center to understand what is being approved and denied by a payer it is useful to set up a database, or relatively simple spreadsheet to document all transplant case decisions by your payers. You will want to track the name of the payer, the indication for which you were seeking authorization, whether the case was approved or denied, and if denied, who denied the request, the reason for the denial, the exact plan type and name of the plan, as well as the date of service requested and the date of the denial and, if included, the physician reviewer's name. You may find it useful to track and know your denial and appeals rates by plan and by indication. You will want to track the final outcome of your appeals.