Payor Denials & Appeals Process
DRG Denials
ACS provides DRG denial management consultation for both coding and clinical validation denials through all levels of appeal when necessary. ACS consultants will review the denial along with all pertinent medical record information in comparison to ICD-10 Official Guidelines for Coding and Reporting, AHA Coding Clinic guidance, prevailing clinical literature, and the hospital’s own clinical definitions (when applicable). Following ACS review, the client will receive one of the following documents:
- A review results letter, provided for educational purposes to explain our rationale for agreeing with the payer denial
- An appeal letter outlining the supporting rationale for the appeal
- When there is partial agreement of the payer denial, both review results and appeal letters will be provided.
ACS reviews are completed within 10 business days following receipt of the denial letter and medical record. When a shorter turnaround is required to meet a payer deadline, every effort will be made to expedite the review.
Admission Necessity Denials
Because of today’s fast-paced and high-volume audit environment, we have partnered with an URAC accredited firm to assist with the appeals process in the event the entire inpatient admission has been denied. Their highly specialized physician advisors are available to assist us with medical necessity review and appeal 24 hours a day, seven days per week.
Physician advisors provide the clinical judgment and risk stratification necessary to prepare an effective medical necessity appeal through all available levels of appeal if necessary.
Outpatient Denials
ACS provides hospital outpatient denial management consultation for both coding and medical necessity denials through all levels of appeal when necessary. ACS consultants will review the denial letter and the entire hospital medical record. An ACS outpatient consultant will evaluate these documents along with all pertinent medical record information in comparison to ICD-10 Official Guidelines for Coding and Reporting, AHA Coding Clinic guidance, CPT / HCPCS guidelines, national and local coverage determinations. Following ACS review, the client will receive one of the following documents:
- A review results letter, provided for educational purposes to explain our rationale for agreeing with the payer denial
- An appeal letter outlining the supporting rationale for the appeal
ACS reviews are completed within 10 business days following receipt of the denial letter and medical record. When a shorter turnaround is required to meet a payer deadline, every effort will be made to expedite the review.
ACS is also available to assist hospitals in preparing appeal letters to challenge incorrect RAC decisions. See Appeals Process / Expert Witness.
