Payers may reject a prior authorization request or procedure claims for a variety of reasons. Reasons for denial may include:
- Clerical errors such as misspellings and transposed numbers
- Questions about medical necessity
- Unfamiliarity with the class of drug
- Improper use of codes
- Insufficient documentation/missing information
Denied coverage or claims may be appealed and potentially reversed. Submitting supporting documentation is a strong factor in the review process. Claims submitted with proper coding and documentation will reduce the likelihood of denials because of technical errors or product unfamiliarity. The following may serve as a guide to the appeals process.
Step One
Review the reasons for the denied claims. Typically, denial codes or written details will accompany the decision. Identify any previously approved SUPPRELIN® LA implants from the same payer.
Step Two
Determine the payer's algorithm for appealing denied claims, including contact information and appeals locations. Typically this information is listed in your provider plan. Medicare contractors provide appeals information on their websites. Submitting documentation to justify the medical necessity of SUPPRELIN LA for the patient may be required. Items to include in the submission to the insurer should include:
- Letter of Medical Necessity, highlighting:
- The patient's medical condition
- Severity of the disease and medical history
- Rationale for SUPPRELIN LA (how it may improve the patient's condition)
- Risks of foregoing SUPPRELIN LA
- Reprints (not photocopies) of peer-reviewed clinical articles and abstracts
- Referring physician letter and/or medical history
Step Three
If denied after the first appeal, active physician involvement may be required to engage the payer and establish medical necessity for the patient. The physician should consider the following options in the appeals process:
- Write a letter of appeal
- Contact the medical director of the payer to present this patient's case
- Discuss alternative payment options with the patient's caregivers
- Consider potential patient advocacy campaign
Step Four
Patients may play an important role in the appeals process. The patient’s plan brochure provides information on claim appeals. Please instruct the family to refer to this document or access the plan’s website for appeals information. Several patient advocacy options may be considered for overturning coverage or claim denials:
- Encourage patient to contact his/her employer’s benefits manager to discuss the situation
- Suggest the family write an appeal letter
- Ask the family to contact the medical director or head of customer or patient relations
- Request that the plan reconsider the original denial
The SUPPRELIN® LA Support Center is available Monday-Friday from 8AM - 6PM EST. toll-free at 1-855-270-0123.