NEDA TOOLKIT for Parents
How to Manage an Appeals Process
The arguments for appeals will be similar if not identical to the arguments provided in the above section. So, in
addition to the arguments already given, here are some tips for filing appeals:
1. Request the specific reason for denial in the
first place. Many reviewers will just cite “does
not meet criteria for medical necessity” as
a reason. This is not good enough. Ask for
specific criterion that is not being met in the
reviewer’s opinion. This will help you formulate
a more concise argument for the appeal.
2. Request a copy of the medical necessity criteria
being used to make the determination. If they
direct you to the website, ask them to guide
you to the correct page over the phone (It
can be very difficult to find online and I have
spoken to plenty of reviewers who struggle
to find it themselves). Having the exact
terminology and wording at your disposal will
also help you to formulate a counter-argument.
3. Request for the next reviewer to be an ED
specialist. They may not always grant the
request, but it does imply that a non-ED doc
may not fully understand the clinical factors
involved in determining the appropriate course
of treatment.
4. Request an expedited appeal. This will speed
up the process and reduce the risk of financial
loss if additional treatment is not authorized.
5. Believe yourself and believe in the patient. It
will come across in your tone.
a) Make sure they are using ED-specific
criteria if they have it. If they are not, you
can make plenty of arguments as to why
it is not an appropriate measure for ED
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