Why is the Pre-Service Appeal more important?

When the new Appeals process became effective in April of 2017, there was much speculation as to how the new process would affect medical providers. It was intended to make the process less onerous with one level of Appeal for each issue. Additionally, under N.J.A.C. 11:2-4.7B all appeals of medical necessity denials are to be Pre-Service Appeals and all other issues are to be appealed with a Post-Service Appeal.  However, some medical providers were appealing medical necessity denials in Post-Service Appeals because the new regulations did not specifically prohibit this.

Recently, PIP carriers have responded by putting new requirements in their Decision Point Review Plans so that all medical necessity denials must be done via a Pre-Service Appeal.  If a medical necessity denial is appealed with a Post-Service Appeal the insurance carrier will deny the claim since it does not comply with the requirements of the Decision Point Review Plan. At arbitration, many DRPs have ruled that failure to comply with a Pre-Service Appeal is a proper basis to deny a demand for arbitration.  In order to avoid this pitfall, it is imperative that medical providers submit timely Pre-Service Appeals once they have received either a denial or modification of a pre-certification request. It needs to be submitted no later than 30 days from when you receive the denial or modification.

What needs to be submitted with a Pre-Service Appeal?

The Pre-Service Appeal must contain the Pre-Service Appeal form. It also must contain an Appeal Rationale Narrative and supporting documentation. The Pre-Service Appeal form must be completed in its entirety. It is extremely important to complete the form with all of the required documentation. This means all the boxes on the form must be filled out.

  • Boxes 1-28. These boxes are relatively straight forward. They ask for claim information, patient information, and provider information. Box 1 asks for the date you are submitting the appeal and Box 2 asks for the date you received the adverse decision. Once again save all fax receipts or other records of dates.
  • Box 30 and 31. These boxes require you to list the CPT Codes, and Dates of Service. You will take this straight from the APTP. A Pre-Service Appeal is to be submitted for each APTP form.
  • Box 31. This box requires you list the CPT Codes. If there is a range of codes that was requested, with no skip, you can indicate that with a dash. For example, 98940-98943. If there is a skip you would use a comma. For example, 98940-98943, 97014, 97012.
  • Box 32. This box would be marked if there is no response within 3 days to your pre-certification request.
  • Box 33. This box lists “administrative dispute” as a reason for Appeal. There has been some confusion as to what constitutes an administrative dispute. Most of the plans include a provision that indicates a failure to properly submit the form and appropriate documentation will constitute and administrative denial. If this happens you would then file another Pre-Service Appeal. If the issue is also medical necessity, you can also check the next box, box 34, for medical necessity. You want to check as many boxes that apply since most of the new Decision Point Review plans indicate that all issues need to be brought up on Appeal and cannot be brought for the first time at arbitration.
  • Box 34 is self-explanatory. This is the box you will check when the services were denied based on medical necessity.

What do I submit with this form?

Make sure to attach the Pre-Service Appeal form, the Appeal Rationale Narrative and supporting documentation. Carriers are denying Appeals based on insufficient documentation if all of the documents are not submitted. Also make sure the form is signed at the bottom. Many insurance carriers and denying Pre-Service Appeals as deficient if the form is not signed.  Box 29 requires that you list the documents you are including with the Pre-Service Appeal. At a minimum, as indicated by the boxes with an asterisk, you must include the following supporting documentation:

  • Original APTP form
  • APTP Decision Response
  • Appeal Rationale narrative

I recommend also submitting, and listing the following in the other documents in this section in the space provided:

  • Diagnostic testing results including MRI and EMG/NCV reports
  • Treatment notes supporting the need for treatment (Must Be Legible!)
  • Referrals to other specialties
  • If the appeal cannot fit onto one form, you must state that there is a second page attached.

Some of Decision Point Review plans state that they don’t want the same documentation submitted. However, I would include it to ensure that the appeal is not denied for lack of documentation. You can never over document with the insurance companies.

What is an Appeal Rationale Narrative in the context of the Pre-Service Appeal?

The Appeal Rationale Narrative is an essential document in the Appeals proceed. It gives the medical provider an opportunity to provide an opinion as to why the denied treatment is medically necessary and clinically indicated. An Appeal Rationale narrative needs to state the following:

  1. First state that it is an Appeal Rationale Narrative in big letters on the top with the date. This way it is clear, and they cannot deny the Appeal for failure to submit this document.
  2. Second, specify the decision you are disagreeing with. For example, I have reviewed the MDR/Peer/IME Review report of Dr. ____________ dated _________ and I respectfully disagree for the following reasons. If you have not been provided with a copy of the Peer Review or IME as of the time you are submitting the Appeal, you will need to state that you were not provided with a copy.
  3. Provide an opinion of why you disagree with the denial. Include results of diagnostic testing, co-morbidities and how they have affected the patient and the treatment, indicate how the patient is showing improvement thorough reduction of pain, increased range of motion, increase in ability to perform activities of daily living, results of objective testing. Also indicate if the patient has been referred to any other specialties and the outcome.
  4. Provide a treatment plan and indicate how the requested treatment will affect the treatment of the patient.
  5. Indicate why further treatment is necessary and if possible, indicate how much further treatment is necessary.

Although it is easier to create a form with a checklist or Appeal Narrative with boiler plate language, the appeal narrative needs to be more specific and in narrative form. Arbitrations can be won with great Appeal Rationale Narratives. It would be good practice to keep it very patient specific.

The Harrell Law Firm Can Help with Your Pre-Service Appeal

In order to ensure that your claim will not be denied for failure to appeal, it is essential to comply with the Appeals process. When medical necessity is the reason for the denial it is imperative that medical providers submit a timely Pre-Service Appeal. Without the Appeal, an arbitration will not be successful. Additionally, a detailed Pre-Service Appeal with a detailed Appeal Narrative and supporting medical records will almost certainly guarantee success at arbitration.

At The Harrell Law firm we can help ensure that you are submitting proper appeals in order to obtain maximum recovery from PIP carriers.

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Leigh A. Raffauf

Partner, Harrell Injury Law

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