An Introduction to REVAssurance 4.5 Government
This tutorial will introduce the basic features of REVAssurance 4.5. It is strongly recommended that you schedule a training workshop to familiarize each user on the maximum benefits of this system.

Although REVAssurance is easy to learn and use, there are certain items you should understand in order to achieve the greatest REVAssurance. This tutorial is designed to show you the basics of the system and get you up and running in a matter of minutes. It does not describe all the many features of benefits from REVAssurance.

These steps assume that you have already installed the REVAssurance folder. REVAssurance is a powerful tool to assist you in recovering denied medical claims. It's over 125 appeal, demand, legal and script forms citing Federal and State statutes and case law can assist you in citing compliance laws to insurers, initiating appeals and resolving denied insurance claims. REVAssurance also offers an Online Service to bring expert help in customizing letters ON-DEMAND.

This version of REVAssurance has a comment feature that will offer you additional case law, consulting and practical tips when creating letters to problematic payors. Each letter with the comment will be highlighted and can be accessed by placing your cursor on the YELLOW [51] BAR or right-clicking it and choosing EDIT COMMENT.

Click here to view a tutorial with basic instructions.

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Steps to Successful Recovery

Verification of Benefits

Securing a verification of benefits from the insurance carrier is the first step a provider should take to secure eventual payment on an account. Many courts have indicated that insurance carriers are liable for information given during the verification process (See Health and Safety Code Section 1371.8 and CA Insurance Code 796.04). It is important that verifiers obtain all the information outlined in the REVAssurance Verification of Benefits form (Case Management Module). If the insurance indicates that a policy exclusion prohibits payment, ask that the exclusion be faxed to your office so that you may assess its applicability to the upcoming treatment. If a carrier indicates the insured is at or near the policy maximum, ask the insurer for the exact amount available for this treatment. If the applicable maximum is calculated on a 12-month basis, you may want to inquire as to when additional benefits will become available.

Claim Follow-up

The patient account staff should begin claim follow-up as soon possible (at least fifteen days) after the claim is filed.If the claim is still in processing when initial follow-up occurs, patient account personnel should remind the insurance processor of any applicable law regarding timely payment of claims (See Untimely Response Letter).

If the carrier needs additional information, we recommend that your office take an active role to assist the carrier with obtaining any reasonably relevant information pertinent to the claim. Reasonably relevant information pursuant to California law means:

The minimum amount of itemized, accurate and material information generated by or in the possession of the provider related to the billed services that enables a claims adjudicator with appropriate training, experience, and competence in timely and accurate claims processing to determine the nature, cost, if applicable, and extent of the plan’s or the plan’s capitated provider’s liability, if any, and to comply with any governmental information requirements (28 CCR Section 1300.71 (a)(10.).

Although the carrier can request additional information, they must explain the necessity of the request to determine payor liability. If they are awaiting COB Information, let them know that you are unaware of any other coverage and to forward any information of other providers of benefits in their possession and the applicable COB/Subrogation Clause. You may want to remind them of their potential loss of a contractual discount if payment is not received within state mandated time frames (See CA Business and Professions Code 657).

Any information provided to the carrier should be faxed whenever possible to speed claim processing.


Fax an untimely Response Letter to the attention of the Director of Claims. Follow-up with the claims director within a few days to ensure that the claim gets prompt attention. Calculate interest and total charges on late payments; remind the claims director that your office expects the interest and full charges if payment is not paid by the applicable deadline. If the interest is not paid in accordance with state law, ask that the legal department review the matter.

Appealing Denied Claims

Any claim appeal should be based on information or lack thereof, in the explanation of benefits. If the carrier indicates there are other problems with the claim, but did not include such information in the EOB, the carrier likely will be unable to raise such issues in future appeal or court proceedings. All reasons for denying a claim should be included in the initial explanation of benefits OR objection letter.

Further, explanations of benefits should be readable and instruct the provider or insured on the process for appealing the denial. If such information is not given, request it immediately as there may be an impending deadline for filing an appeal. You should also review any applicable utilization review laws (See Medical Necessity - State Laws) to see if the denial is in compliance with these mandates. Many states specify within the utilization review statute specific procedures for denying claims.

You may want to review several different REVAssurance master letters to see which most specifically addresses the issues raised in the explanation of benefits. Further, each master letter should be cut and pasted to a word document (with your letterhead) and edited by your staff to include specifics regarding each claim, which support your request for payment. The master letters will not always cover your specific argument, which might be applicable to the claim. So here are a few hints for successfully appealing denials:
  • If the plan is self-insured (ERISA), obtain a copy of the policy and/or the Summary Plan Description. 29 U.S.C. § 1132(c) requires ERISA plan information to be provided within thirty (30) daysfrom the receipt of the request. Failure to supply the above requested information within thirty days of date of this letter may subject the plan to a penalty of $110.00 per day and other costs.
  • Locate any policy clause which appears to indicate that the claim is payable and cite this information in your appeal letter. The insurer is bound by policy wording and utilizing contract wording can be a highly effective appeal tactic.
  • If your letter cites statutory or case law to support your position, ask the legal department to review the claim file for compliance with the information cited in your appeal letter. Follow up with the legal department frequently to ensure that there are no delays in getting a complete response.
  • If the coverage is self-funded, file the appeal with the employer. The employer has final authority on all self-funded claims.
  • Tenacity is often the key to overturning a denied claim. If you believe statutory codes and/or the policy terms indicate payment, continue to appeal the claim to the Company President or other upper management decision-makers. You may also want to file a grievance with applicable state insurance department or ask the patient to pursue such a grievance.

If your appeal is successful, be sure to seek interest payments as outlined above. If you are unable to overturn the denial, you want to assess such claims for other payment avenues - such as Victim's Compensation claim payment, public assistance eligibility or third party liability claims-and involve the appropriate regulatory agency.

ERN Enterprises, the developer of REVAssurance, also offers Emergency Claims Representation to its provider membership. Our experienced consultants will carefully review all account placements for additional case and statutory law, which supports your appeal position. We will pursue the carrier and attempt to locate any other potential payor on your problematic claims.

On successfully appealed claims, we will provide copies of the letters (for an additional fee) used to overturn the denial so that you may add them to REVAssurance for your future use. Our consulting fees are based upon any amount recovered on placed accounts; there is no cost to you if we are unable to successfully recover benefits. Please contact us for more details at (714) 995-6900 ext: 6913.

DISCLAIMER: ERN Enterprises is not acting as your attorney in connection with delayed or denied claims for medical coverage by various insurance companies. ERN Enterprises training services do not constitute legal advice or legal consultation and do not establish an attorney-client relationship. The determination of the need for legal services and the choice of legal counsel are the sole responsibility of the Provider. You are encouraged to seek independent legal advice at your sole discretion. © 2015; Author: Ed Norwood; Project Administrator: Princeton Legree