Including payer payment guidelines in your appeal letter templates can increase the efficiency and effectiveness of your appeal writing. Most payers develop and publish very specific payment guidelines for medical and surgical procedures. This ensures payment is made only for services that are medically necessary to effectively treat a person in a medically effective but also fiscally responsible (read least expensive) way. CMS publishes these payment guidelines as National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Commercial payers often times publish their payment guidelines as Clinical Policy Bulletins (CPB), Medical Policies, or other similar titles. It’s generally easy to find these guidelines on the Internet. CMS has a Medicare Coverage Database (MCD) that can be accessed at http://www.cms.gov/medicare-coverage-database/. You can find both NCDs and LCDs there. Most commercial payers publish their CPBs in the Provider area of their public websites. You must also consider if your provider organization is contracted with the payer and whether there are additional coverage policies that may apply.

[Read more…]