How do I know when to appeal a denial?
Quick Answer
Appeal when the claim is correct as billed, you disagree with the payer decision, and you have evidence that supports payment. Do not appeal a claim that simply needs a billing correction, COB update, eligibility fix, coding correction, or missing information.
Step-by-Step Instructions
Make sure the claim itself is correct first
Before appealing, verify the patient, payer, CPT/HCPCS, diagnosis, modifiers, provider information, authorization, COB, and claim history. If the original claim is wrong, correct the claim instead of appealing.
Appeal when you disagree with the payer decision
Common appeal situations include medical necessity when documentation supports the service, authorization denials when an exception or prior approval evidence exists, bundling denials after Coding confirms separate payment is supported, and timely filing denials when you have proof of timely submission.
Use reconsideration when the payer offers a lower-level review first
Some payers require or prefer reconsideration before a formal appeal. Reconsideration is often appropriate when the payer can reprocess the claim using additional information without a full formal appeal.
Do not appeal a correctable billing error
Missing modifier, wrong diagnosis, invalid member ID, wrong provider data, or another claim-data error normally belongs in a corrected claim. Appeals dispute payer decisions; corrected claims fix your submission.
Do not appeal routine COB or eligibility problems first
If the wrong payer was billed, coverage order is wrong, or eligibility information is incorrect, fix the administrative problem and submit to the correct payer.
Build the appeal around evidence
State exactly why the payer decision should change. Attach the relevant EOB/ERA, medical records, authorization proof, timely filing proof, coding review, payer policy, or other documentation that supports the requested payment.
Track the deadline and proof of submission
Document the appeal filing deadline, submission date, portal confirmation, fax confirmation, mailing proof, and next follow-up date. Do not submit duplicate appeals through multiple channels unless the payer instructs you to.
Common Mistakes to Avoid
Appealing a claim that contains an obvious billing error.
Submitting a generic appeal without explaining the exact denial and requested outcome.
Sending medical records without a rationale tying them to the denial.
Missing the appeal deadline.
Submitting the same appeal through portal, fax, and mail at the same time.
Appealing before Coding or Authorization finishes a required internal review.