Member & Provider Appeals
Our Health Care Advocates provide guidance and assistance for Provider Appeals, Medical Director Review, Member Appeals, Member Grievance, and Medicare Administrative Law Judge (ALJ) cases. In many cases, we work directly with the physician, reviewing the medical information and providing guidance in drafting the necessary correspondence.
What you need to consider when deciding whether to hire a professional Nurse Advocate or to process the appeal yourself:
Remember: You Can Go Through The Appeal Process Only ONCE!
If you lose, you cannot go through the process again.
* You need extensive knowledge on what it takes to win an appeal or ALJ case.
* Are you well versed in healthcare policy as well as health insurance policies, procedures, medical
policies, and claims adjudication processes?
* Are you clinically savvy to the point where you can speak and defend your case on equal par with
physicians and nurses who specialize in your clinical situation?
* Are you able to draft appeal correspondence that will become part of your medical and legal record and will be entered into the appeal or ALJ case as evidence?
Our Nurses will file the member appeals or member grievance directly for the member
or caregiver and facilitate the entire process from start to finish, including attending the appeal in-person (if geographically feasible) or via teleconference.
For Medicare patients and their caregivers, we will file their Medicare Appeals, working with the social
worker, case manager, and physician where appropriate, up to and including presenting Administrative Law Judge (ALJ) cases, which is required in a third level appeal for Medicare.
For physicians, we provide assistance and consultative guidance to ensure they are
navigating the appeal process with the least amount of disruption to their office while also working to maximize the outcome for their patient.
The Appeal process for both private insurance and Medicare, a government program, is our expertise. Wording is critical, knowing how to write an appeal letter or request for ALJ review is paramount. If you have any doubt as to the best path forward for you or a loved one, please reach out to us - we can help.
Allow our Health Care Advocates to do what we do best and help you through this difficult time.
What you need to consider when deciding whether to hire a professional Nurse Advocate or to process the appeal yourself:
Remember: You Can Go Through The Appeal Process Only ONCE!
If you lose, you cannot go through the process again.
* You need extensive knowledge on what it takes to win an appeal or ALJ case.
* Are you well versed in healthcare policy as well as health insurance policies, procedures, medical
policies, and claims adjudication processes?
* Are you clinically savvy to the point where you can speak and defend your case on equal par with
physicians and nurses who specialize in your clinical situation?
* Are you able to draft appeal correspondence that will become part of your medical and legal record and will be entered into the appeal or ALJ case as evidence?
Our Nurses will file the member appeals or member grievance directly for the member
or caregiver and facilitate the entire process from start to finish, including attending the appeal in-person (if geographically feasible) or via teleconference.
For Medicare patients and their caregivers, we will file their Medicare Appeals, working with the social
worker, case manager, and physician where appropriate, up to and including presenting Administrative Law Judge (ALJ) cases, which is required in a third level appeal for Medicare.
For physicians, we provide assistance and consultative guidance to ensure they are
navigating the appeal process with the least amount of disruption to their office while also working to maximize the outcome for their patient.
The Appeal process for both private insurance and Medicare, a government program, is our expertise. Wording is critical, knowing how to write an appeal letter or request for ALJ review is paramount. If you have any doubt as to the best path forward for you or a loved one, please reach out to us - we can help.
Allow our Health Care Advocates to do what we do best and help you through this difficult time.
