Appeals Processing

It is the work of getting a denied claim reconsidered. Someone reads the denial reason and remark codes (CARC and RARC), decides whether the claim was denied correctly, and fixes what can be fixed. For what can’t, they write an appeal with the medical record and any payer policy that supports payment, then file it before the deadline.

Most denied claims never get appealed because staff are busy with new claims. An appeals team works the denial backlog on its own schedule. We start as soon as a denial posts, which keeps you inside the appeal window and shortens the wait for payment. We also work smaller claims that in-house teams skip, since several small denials from one payer can add up to more than one large one.

Nearly any denial can be appealed, but some are worth more effort than others. Medical necessity denials, authorization denials, bundling and modifier denials, and underpayments against the contract are the common ones. Some denials, such as a duplicate claim or an eligibility error, call for a corrected claim and not an appeal. We decide which route fits each denial before we file anything.

We handle Medicare, Medicaid, worker’scompensation and attorney-related claims. For each denial we read the payer’s policy, build the appeal around that denial’s specifics and attach the records that support it. Generic letter templates get rejected a second time, so we don’t use them. We also log every deadline, because Medicare redetermination requests are due within 120 days and commercial plans often allow 60 to 180. After filing, we follow up with the payer until there is a decision.

Appeals need a person who can read a payer policy, pull the right chart notes and keep track of deadlines across dozens of open denials. Most billing offices don’t have that person free. Outsourcing also surfaces patterns. If one payer keeps denying the same CPT code, we report it so the front end can fix the cause and stop sending claims that will bounce.