Appeal Templates
This page will describe the dynamic appeal templates available within GoRev. More information on utilizing these dynamic templates can be found in our Charts Tutorial.
Important Note: The use of appeals is always up to your own personal judgment and GoRev is not responsible for any improper use of the following templates.
If you do not see these Templates in your GoRev unit, please contact GoRev support.
Appeals Currently Available
Prudent Layperson Law
This appeal can be utilized whenever a carrier denies an emergency room claim for no authorization, precertification required, or medical necessity reasoning. This is Texas specific language however, other states have similar layperson standards defining what is and isn't “emergent.”
You can simply copy and paste this template into your GoRev server for use.
ER Allowable Appeal
This appeal is primarily for situations where the provider is out of network and the carrier has applies a reduction citing some source as their “market reasonable fee.” The problem is these carriers rarely have legal authority to request such a discount. This appeal is specific to emergency rooms only.
You can simply copy and paste this template into your GoRev server for use.
Example Medical Necessity Appeal
This appeal is created using the resources detailed in the Denial management guide for CAS code 50 (denied for medical necessity). You will need to refer to each payers website and pull specific medical policies related to the procedure on the claim you are appealing. You will need to replace the policy number and coverage details sections in this appeal template each time you use it. As an example, this appeal is formatted for a BCBS spinal neurostimulator medical necessity denial response.
You can simply copy and paste this template into your GoRev server for use.
medical_necessity_appeal_spinal_cord_bcbs.docx
Patient Contact Additional Info I
A simple patient contact letter asking them to respond with insurance coverage information necessary to get a claim paid.
You can simply copy and paste this template into your GoRev server for use.
Patient Contact Additional Info II
You can use this patient contact letter to escalate after using patient contact tier I.
You can simply copy and paste this template into your GoRev server for use.
Patient Contact Coordination of bennifits appeal
This patient contact incentivises the patient to participate in overturning a coordination of benefits denial. Keep in mind, in the state of Texas carriers are not allowed to utilize COB denials to hold payment beyond the Texas Clean Claim statute's timelines (30 days for electronic claims, 45 days for paper claims). You should use the Texas COB appeals first if you are operating in this state.
You can simply copy and paste this template into your GoRev server for use.
Texas 180 Day Refund Refusal Appeal
This appeal can be used to decline a refund request when the carrier has violated the timeline indicated in the Texas Clean Claim act. Carriers may only have 180 days from date of payment to request a refund in the state of Texas.
You can simply copy and paste this template into your GoRev server for use.
texas_180_day_refund_denial.docx
Duplicate Claim Appeal
This appeal can be used to decline a refund request when the carrier has violated the timeline indicated in the Texas Clean Claim act. Carriers may only have 180 days from date of payment to request a refund in the state of Texas.
You can simply copy and paste this template into your GoRev server for use.
texas_180_day_refund_denial.docx
Bundling Guidelines Appeal
This appeal can be used to decline a refund request when the carrier has violated the timeline indicated in the Texas Clean Claim act. Carriers may only have 180 days from date of payment to request a refund in the state of Texas.
You can simply copy and paste this template into your GoRev server for use.
texas_180_day_refund_denial.docx
Texas Coordination Of Benefits Appeal
Texas has strict laws in place detailing when a carrier can and cannot utilize coordination of benefits to deny a claim. You can see the detail of this law here: 201401026-1.pdf
This appeal cites language from this law.
You can simply copy and paste this template into your GoRev server for use.
texas_cordination_of_benefits.docx
Texas COB Recovery LAw Appeal
Texas has strict laws in place detailing when a carrier can and cannot utilize coordination of benefits to deny a claim. Similarly the law details the requirements a carrier must abide by in order to request a refund related to coordination of benefits. 201401026-1.pdf
This appeal cites language from this law.
You can simply copy and paste this template into your GoRev server for use.
ERISA Reglatory Complaint Appeal
There are typically only three paths to escalate a claim beyond an insurance carrier's denial of your appeals.
For Medicare you must submit your appeal through your MAC first and then through the ALJ (Administrative law Judge) process.
For commercial carriers, if the plan is fully funded you may be able to submit a complaint directly to the insurance commissioner of your state. For example, Texas' is here: http://www.tdi.texas.gov/
For any commercial plan that is self funded you must utilize the ERISA statue to escalate. The appeal here is related to ERISA usage.
You can simply copy and paste this template into your GoRev server for use.
erisa_regulatory_complaint.docx
Texas TDI Compalint
There are typically only three paths to escalate a claim beyond an insurance carrier's denial of your appeals.
For Medicare you must submit your appeal through your MAC first and then through the ALJ (Administrative law Judge) process.
For commercial carriers, if the plan is fully funded you may be able to submit a complaint directly to the insurance commissioner of your state. For example, Texas' is here: http://www.tdi.texas.gov/
For any commercial plan that is self funded you must utilize the ERISA statue to escalate.
This appeal template will automatically fill out a TDI complaint form for you.
You can simply copy and paste this template into your GoRev server for use.
Allowable Appeal I
This appeal is primarily for situations where the provider is out of network and the carrier has applies a reduction citing some source as their “market reasonable fee.” The problem is these carriers rarely have legal authority to request such a discount. This appeal can be used as tier I. A second appeal exists titled Allowable Tier II that can be used to escalate when no response is received.
You can simply copy and paste this template into your GoRev server for use.
Allowable Appeal II
This appeal is primarily for situations where the provider is out of network and the carrier has applies a reduction citing some source as their “market reasonable fee.” The problem is these carriers rarely have legal authority to request such a discount. This appeal can be used as the escalation tier II appeal.
You can simply copy and paste this template into your GoRev server for use.
Texas Clean Claim Act Timeline Appeal
This appeal requires extensive research on your part and collection of supporting documentation. If done correctly, this appeal may force the carrier to submit additional payment to you per the Texas Clean Claim Act regulations cited.
You can simply copy and paste this template into your GoRev server for use.
texas_clean_claim_act_timeline.docx
Timely Filing Wrong Insurance Appeal
You may be able to use this appeal template to overturn timely filing when you have submitted a claim to the wrong insurance carrier originally.
You can simply copy and paste this template into your GoRev server for use.
timely_filing_filed_to_wrong_insurance.docx
Timely Filing General Appeal
This appeal template may help you overturn a timely filing denial when you have truly submitted a claim timely.
You can simply copy and paste this template into your GoRev server for use.
GOREV SUPPORT TEAM
If you have any additional questions or concerns regarding this tutorial, please contact the GoRev Support Team by phone at (317) 794-3900 or by email at ask@gorev.com
Note: Always submit an IT Support Ticket detailing the problem that you are experiencing with this portion of GoRev, if possible, as this will give GoRev Support Agents access to information that will help expedite the resolution of your issue. If you are unsure how to submit an IT Support Ticket in GoRev, please see the IT Support Ticket Creation tutorial for assistance.