Appeal Submission Follow-Up Script

APPEAL SUBMISSION FOLLOW-UP CALL SCRIPT ═══════════════════════════════════════ BEFORE THE CALL ═══════════════════════════════════════ Call within 7 days of submitting an appeal. Have ready: - Patient name and date of birth - Member ID and group number - Appeal reference number ([APPEAL_REFERENCE_NUMBER]) - Original claim number ([CLAIM_NUMBER]) and date of service ([DATE_OF_SERVICE]) - Appeal submission date and method (fax, electronic, mail) - Fax confirmation or electronic submission receipt - CARC code being appealed and brief summary of the appeal basis Open a call log entry. Record the call start time. ═══════════════════════════════════════ OPENING ═══════════════════════════════════════ "Good [morning/afternoon], this is [YOUR_NAME] calling from [PRACTICE_NAME] to confirm receipt of an appeal submission. Member ID is [MEMBER_ID]. The patient is [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME], date of birth [PATIENT_DOB]. The original claim number is [CLAIM_NUMBER], date of service [DATE_OF_SERVICE]. The appeal was submitted on [APPEAL_SUBMISSION_DATE] via [SUBMISSION_METHOD], appealing CARC [CARC_CODE]. May I have your name and a reference number for this call?" → Record: representative name, call reference number, date and time. ═══════════════════════════════════════ CONFIRM RECEIPT ═══════════════════════════════════════ "Can you confirm that the appeal was received, that all enclosed documentation was logged, and that the appeal has been assigned an appeal reference number?" If receipt is confirmed: "Please confirm the appeal reference number, the assigned reviewer or review queue, and the expected decision date." If receipt cannot be confirmed: "I have a [fax confirmation / electronic submission receipt] dated [SUBMISSION_DATE] showing successful transmission. Can you check under the patient name, member ID, claim number, and submission date? Please also escalate to a supervisor if the appeal cannot be located." ═══════════════════════════════════════ REVIEW TIMELINE ═══════════════════════════════════════ "What is the review timeline for this appeal? Per [PAYER_NAME] policy, [STANDARD_DECISION_DAYS]-day decision applies for standard appeals. Can you confirm the expected decision date and the contact for status updates?" If the appeal is in clinical review: "Is a peer-to-peer review available before the final decision, and if so, what is the scheduling window and the contact?" If the appeal is in administrative review: "What additional documentation, if any, is requested? If the file is complete, when will the decision be issued?" ═══════════════════════════════════════ PAST 30-DAY DECISION WINDOW ═══════════════════════════════════════ If the appeal is past the stated decision window: "The appeal was submitted on [APPEAL_SUBMISSION_DATE], which is now [DAYS_OUTSTANDING] days outstanding. Per [PAYER_NAME] appeal review policy, decisions are required within [POLICY_DAYS] days. Can you escalate this to the appeals supervisor and provide a reference number for the escalation?" → Document the supervisor name, direct callback, and the escalation reference. If no supervisor is available, document the refusal and proceed to the next escalation step in your office's appeal protocol. ═══════════════════════════════════════ DOCUMENT THE CONVERSATION ═══════════════════════════════════════ Before ending the call: "Please send written confirmation of the appeal status, the assigned reviewer, the expected decision date, and the call reference number to [PRACTICE_FAX] or to the payer portal under member [MEMBER_ID]." In the call log, record verbatim: - The appeal status as stated - The expected decision date - Any commitment from the representative (callback, written confirmation, supervisor escalation) - The call reference number and representative name ═══════════════════════════════════════ WHEN TO FILE A STATE INSURANCE COMPLAINT ═══════════════════════════════════════ Consider escalating to the state department of insurance when: - The appeal is more than [POLICY_DAYS] days past the stated decision window with no resolution - The payer cannot locate the appeal despite documented submission proof - The payer refuses to issue a written decision - A pattern of appeal-handling failures appears across multiple claims for the same payer Before filing, gather: submission proof, all call logs, written confirmations (or documentation of refusal), and the original CARC denial. The state complaint reference strengthens your position in subsequent payer communications. ═══════════════════════════════════════ AFTER THE CALL ═══════════════════════════════════════ Calendar the next follow-up: - 7 days after submission for receipt confirmation (this call) - Halfway through the stated decision window - The day after the stated decision window if no decision has been issued