Mastering Denied Eye Care Insurance Claim Appeals

Are you frustrated with eye care insurance and vision plan claims being denied? Dealing with denied claims is a common part of running a practice. However, knowing how to appeal a claim can protect your revenue and ensure patients get the care they need.

Do not despair; there are ways to appeal and win your claim. In this blog, we'll share tips to help you successfully navigate the denied claim appeal process.

Review the Claim Denial Letter

It’s important to understand the appeal process. Start by reviewing the denial letter and the Explanation of Benefits (EOB) to identify the reason for the denial. Gather all necessary documentation and evidence to support your claim.

Insurance companies usually provide a claim denial code and a brief explanation. Common reasons for denials include coding errors, lack of medical necessity, or incomplete documentation.

Claim denials fall into three categories: administrative, clinical and policy. Most claim denials are due to administrative errors. For instance, if the procedure code is inconsistent with the modifier you used, or the required modifier is missing for the decision process, your claim will be denied.

TIP: Keep a database of denial reasons for each payer's denial to identify trends and recurring issues.

Related: Mastering Claim Denial Reason Codes Expedites Cash Flow

Include a Detailed Explanation with the Denial Letter

When submitting your claim appeal, include a detailed explanation of why you believe your claim should be approved.

Strong appeals rely on strong documentation. Include detailed exam notes, diagnostic results (e.g., OCT, visual field tests), treatment plans, and any correspondence with the patient. Clearly demonstrate the medical necessity of the procedure or service.

It is also important to know the Appeal Filing Limit (AFL) days after the initial denial date on the letter. Most insurance companies allow 45 to 60 days to file an appeal if the provider believes the denial was incorrect.

Be persistent when appealing medical or vision plan claims. The appeals process can be lengthy and frustrating, but do not give up. Keep track of deadlines and regularly follow up with the insurance company to ensure your appeal is being reviewed.

TIP: Use bullet points and bold text within the denial letter to highlight key clinical findings and rationale.

Double-check Billing Codes and Modifiers are Correct

Even minor coding errors can lead to denials. Ensure that CPT®, ICD-10, and modifier codes are accurate and support the billed services. Assigning the correct diagnosis codes, procedure codes, and modifiers is critical.

TIP: Conducting coding audits can serve as a valuable internal check.

Related: Insurance Billing Codes and Modifiers: What’s the Difference and Why It Matters and How (and How Not) to Use Common Medical Billing Modifiers

Write a Clear, Concise Appeal Letter

A well-written appeal letter is your opportunity to tell the patient’s story. Keep it professional, structured, and factual. Include the date of service, patient name, claim number, and a summary of why the service was medically necessary.

TIP: Personalize the letter when appropriate, explaining how the procedure or service impacted the patient’s vision or quality of life.

Track and Follow Up Regularly

Once your appeal is submitted, keep track of it. Set reminders to follow up within the insurer’s stated timeframe. Document all phone calls and written communications in case further action is needed.

TIP: Designate a staff member to manage claim appeals and follow up regularly.

Seek Assistance from the Insurance or Vision Plan Company

Another critical factor is to seek assistance if needed. Many insurance companies have customer service representatives or appeal specialists who can help guide you through the process.

TIP: Consult with a certified medical coder or billing specialist for complex cases.

Related: Preparing for a Vision Plan and Medical Insurance Billing Audit

Navigate the Claim Appeal Process with an RCM Consultant

Staying on top of optometry and ophthalmology medical billing rules, regulations, and code changes is frustrating and time-consuming. While appealing a medical or vision plan claim can be daunting, with the right knowledge and persistence, it is possible to win your appeal.

Outsourcing your medical billing and revenue cycle management (RCM) allows you to focus on patient care without worrying about provider credentialing and enrollment, insurance eligibility verification, staff vacations, unplanned sick days, turnover, or costly retraining.

At Fast Pay Health, we take patient health information (PHI) security and privacy seriously. We train and monitor our billing consultants continuously to comply with current PHI and HIPAA rules. Our team uses your practice management software (we work with any eye care software) to minimize further security risks, prepare and transmit claims, post insurance payments, and run necessary reports.

Request a free RCM consultation today and start enjoying the advantages of cleaner claims. Learn how Fast Pay Health RCM services take a proactive approach to help you get paid faster and improve the financial performance of your practice.