Second Level Appeals

Below are some common questions regarding second level appeals

A second level appeal is used when the original or initial appeal does not convince the health plan to overturn the denial and pay the claim.  The second level appeal offers additional information and potentially stronger language to entice the health plan to pay the claim. 

A second level appeal is always provided at no cost when ordering an appeal letter for any other denial reason.

Issue Description
What is a Second Level Appeal? After an initial appeal to the health plan is not considered or does not overturn the denial, a second level appeal elevates the situation to the health plan.
What is Required with a Second Level Appeal? It usually must be performed within a certain time frame after the health plan's denies the first level appeal.  Additional information must be usually included with the second level appeal to be considered that was not submitted in the first appeal.   Submit an appeal letter describing your argument, any supporting documentation and/or medical records (if a clinical appeal), a copy of the original claim, the explanation of benefits and make sure that it is mailed to the correct location.  Often times the Appeal Address is different than the address where claims are usually submitted for consideration.
Who Reviews a Second Level Appeal? The health plan reviewer of the second level appeal is usually not the reviewer of the first appeal.  It may be a nurse or physician.
What are the Chances of a Health Plan Approving a Second Level Appeal? Actually, many people are unaware that they could continue to appeal a claim denial, as long as they meet the time requirements and have additional supporting documentation/information.  The success rate of 2nd level appeals runs approximately 30-40%.