3 Killer Examples of Effective Appeal Letters for Timely Filing Denials

$262 billion worth of claims get denied on an annual basis according to HFMA. If you ran the math and divided that number by the total number of healthcare providers in the U.S., it would amount to around $5 million worth of denials per.

That’s an insane statistic.

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If the average dollar amount of denials costs providers that much, regardless of the size of their practice, how are they supposed to keep their doors open?

I have to admit, the purpose of the statistic at the beginning was to grab your attention. Your organization’s average denial rate is going to be different from the mental health facility up the street.

Regardless of that point, though, more than 85% of denials are potentially avoidable and one-third of them are absolutely avoidable.

Of course, the next piece of that puzzle is determining the most common types of denials your organization sees the most.

With over 20 years of experience with helping providers manage and appeal their denials, there’s one type of denial that we constantly see our clients run into, timely filing denials.

The first timely filing denial appeal letter I have for you is a reconsideration request. Believe it or not, there are situations where you can appeal a timely filing denial.

Insurance organizations allow for providers to submit reconsideration requests on denied claims. Of course, reconsideration requests aren’t as easy as they sound. Like with submitting claims, submitting a reconsideration request also means jumping through a lot of hoops.
Frankly, reconsideration requests are arguably more difficult than submitting claims.

Insurance companies detail their reconsideration request criteria within a massive, 500 plus document called a provider manual…usually right under timely filing requirements.

Ironically, timely filing reconsideration requests come with a deadline as well. Here’s an example of a provider manual that mentions timely filing reconsideration requests from Vermont Medicaid.

Here’s an example of a timely filing appeal letter based on Vermont Medicaid’s timely filing reconsideration request section.

The most important aspect to keep in mind when sending your appeal letter for a timely filing denial is documentation. You need to make sure that you provide the letter, the denial in question and documentation as to why it qualifies for reconsideration.

It’s also a good idea to cite the reconsideration request requirements within the insurance organization’s provider manual within your letter.

The second example I have for you is actually a reconsideration form.

Similarly to how insurance organizations receive truckloads of claims every day, they also get hit with a lot of appeal letters. Of course, the appeal letters they receive are only a fraction of the amount of denials they send out.

The truth is that some providers don’t even bother with denials and just write them off as a loss.

Even though the amount of appeal letters received isn’t as high compared to claims, insurance organizations will sometimes mandate reconsideration forms.

This next appeal letter for timely filing sample is exactly that, a templated form provided by an insurance organization for reconsideration.

Of course, it comes from Vermont Medicaid.

This form has to be filled out for Vermont Medicaid to even consider appealing a timely filing denial.

Since every payer is different, you’ll need to find and download the reconsideration forms from those who require it. Usually, these forms are found in the payer portal online or within its provider manual.

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