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At the ACA, we understand the limited time providers have to write appeals. When a denial is received, understandably, providers are frustrated and may feel that it may not be worth their time to appeal. However, it is vitally important to the chiropractic profession and your patients that you appeal all denials, whether they are pre-service restrictions, restrictions of continued care, or down-coded and bundled claims, etc. Though, we all know this, it is good to remember that any appeal must be accompanied by appropriate documentation showing medical necessity. For this reason, the ACA has developed a process to assist providers when an adverse determination is received.
If an adverse determination is received, simply follow the steps outlined below.
1. If the procedures billed are bundled or denied→ Read ACA’s Coding Clarifications to ensure you are coding properly.
2. If there is no coding clarification which describes the issue→ Access ACA’s Coding Resource Center for more information.
3. If your documentation does not support every service that you billed you will have great difficulty in overturning the insurer’s determination.→ Review your documentation to ensure the procedures billed are supported in the patient health record and compare your documentation to the ACA documentation guidelines.
4. If your coding and documentation is in accordance with outlined ACA and CPT® coding and documentation guidelines→ Use ACA’s Template Appeal Letter that pertains to the situation you are experiencing.
5. Visit our state insurance regulations page to determine if any of the information from your state insurance regulations supports your appeal. Be certain to send ACA a copy of your appeal.
6. If you receive no response or an affirmation of a previous denial in response to your appeal→ Follow the insurer’s instructions for a second level appeal.
7. If you receive no response or an affirmation of a previous denial in response to your secondary appeal→ Notify your Department of Insurance(DOI) of the problem and provide the DOI all correspondence and responses sent to and received from the insurer. Please note that if a third party administrator is involved in the problem you have experienced, it is necessary to report the insurer involved to the DOI. DOIs often do not have regulatory authority over third party administrators.
8. To Notify your DOI→Verify your DOI’s address and determine if additional paperwork needs to be submitted with a complaint.
**Please note that if the insurance plan is an ERISA plan, a specific appeal process must be followed. Access ACA's information on ERISA for more information.
If you have any questions about this process, please contact insinfo@acatoday.org
Template Appeal letters
Please be sure to review our template letters instructions sheet before sending any appeals.
Denials of massage with CMT
Denials of manual therapy with CMT
Denials based on CCI edits
Denials of EM services with CMT
Denials of hot and cold packs
Denials based on medical necessity
Denials of physical medicine services performed by DCs
Denials of acupuncture with electrical stimulation
Denials of Strapping Codes
Denials based on care type (supportive/maintenance)
Appeal regarding E/M level authorized
Appeal regarding CMT level authorized
Possible state regulation violation--failure to meet adverse determination requirements
Possible state regulation violation--failure to meet response time requirements
Please note: Research can bolster your appeals. Review our overviews of cost-effectiveness and efficacy research pertaining to the services that doctors of chiropractic provide.
CPT is a registered trademark of the American Medical Association
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