CO-197 Appeal Letter

[PRACTICE_NAME] [PRACTICE_ADDRESS] [PRACTICE_CITY_STATE_ZIP] [PRACTICE_PHONE] [PRACTICE_FAX] NPI: [RENDERING_PROVIDER_NPI] Tax ID: [PRACTICE_TAX_ID] [DATE] [PAYER_NAME] [PAYER_APPEALS_DEPARTMENT] [PAYER_ADDRESS] [PAYER_CITY_STATE_ZIP] Re: Appeal of Claim Denial -- CARC CO-197 (Precertification/Authorization/Notification Absent) Patient Name: [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME] Member ID: [MEMBER_ID] Date of Service: [DATE_OF_SERVICE] Claim Number: [CLAIM_NUMBER] Authorization Number: [AUTH_NUMBER] Dear Appeals Review Committee: I am writing to appeal the denial of the above-referenced claim under CARC CO-197. This denial indicates that precertification, authorization, or notification was absent. We respectfully submit that this denial is in error for the following reason(s): [SELECT ONE OR MORE -- DELETE UNUSED PARAGRAPHS] OPTION A -- AUTHORIZATION WAS OBTAINED PRIOR TO SERVICE: Authorization number [AUTH_NUMBER] was issued by [PAYER_NAME] on [AUTH_ISSUE_DATE] for the services rendered on [DATE_OF_SERVICE]. The authorization covered [AUTHORIZED_PROCEDURE_CODES] for the period [AUTH_START_DATE] through [AUTH_END_DATE]. A copy of the authorization confirmation is enclosed. We believe the authorization reference was not matched during claims processing and request re-adjudication with the enclosed documentation. OPTION B -- RETROACTIVE AUTHORIZATION IS PERMISSIBLE: Per [PAYER_NAME] policy [POLICY_NUMBER_OR_SECTION], retroactive authorization is permitted when [QUALIFYING_CONDITION]. The service was rendered on [DATE_OF_SERVICE] due to [CLINICAL_JUSTIFICATION]. We have since obtained retroactive authorization number [RETRO_AUTH_NUMBER] on [RETRO_AUTH_DATE]. Documentation of the retroactive authorization is enclosed. OPTION C -- SERVICE MEETS EMERGENT/URGENT EXCEPTION: The service provided on [DATE_OF_SERVICE] was medically necessary on an emergent/urgent basis. Per [PAYER_NAME] emergency exception policy, prior authorization is not required when the patient presents with [EMERGENT_CONDITION]. The treating provider determined that delaying care to obtain authorization would have resulted in [CLINICAL_RISK]. Supporting clinical documentation is enclosed. MEDICAL NECESSITY: [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME] presented on [DATE_OF_SERVICE] with [DIAGNOSIS_DESCRIPTION] (ICD-10: [ICD_10_CODE]). The procedure(s) [CPT_CODES] were performed based on the following clinical indicators: [CLINICAL_INDICATORS]. This treatment is consistent with [RELEVANT_NCD_LCD_REFERENCE] and accepted standards of care for [CONDITION]. ENCLOSED DOCUMENTATION: 1. Copy of authorization confirmation (if applicable) 2. Clinical notes from [DATE_OF_SERVICE] 3. Relevant diagnostic results supporting medical necessity 4. [PAYER_NAME] policy section referenced above 5. NCD/LCD reference: [NCD_LCD_NUMBER] -- [NCD_LCD_TITLE] 6. Any additional supporting documentation: [LIST_ADDITIONAL_DOCS] We request that this claim be re-adjudicated based on the enclosed documentation. Per your appeal filing requirements, this appeal is submitted within the [APPEAL_DEADLINE_DAYS]-day filing window from the date of the Explanation of Benefits dated [EOB_DATE]. If additional information is needed, please contact our office at [PRACTICE_PHONE]. Respectfully, [PROVIDER_NAME], [PROVIDER_CREDENTIALS] [PROVIDER_TITLE] NPI: [RENDERING_PROVIDER_NPI] Enclosures: [NUMBER_OF_ENCLOSURES] cc: Patient file