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Beginner Denial Workflow

Payer Appeal & Reconsideration Submission Guide

Learn what to send, where to send it, and when an appeal is actually appropriate. Start with the denial reason first, then use the payer-specific channel below.

Submission methods last verified 2026-09-02

First Decide What You Are Actually Sending

Corrected claim

The original claim itself was wrong or incomplete.

Examples: Wrong diagnosis, missing modifier, invalid CPT/HCPCS, incorrect member ID, wrong provider field.

Reconsideration

The claim was processed, but you want the payer to review it again, often with added information or a processing correction.

Examples: Payer processed against the wrong edit, additional information can resolve it, claim should be reprocessed.

Appeal

You disagree with the payer decision and can explain why payment should be made.

Examples: Medical necessity, authorization exception, bundling dispute after coding confirms billing, timely filing with proof.

Coding review

Resolving the denial requires someone to choose, change, or defend CPT/HCPCS, ICD-10, modifiers, code pairs, or NCCI logic.

Examples: CO-97, CO-190, CO-11, modifier denials, M86 same/similar, CO-50 when diagnosis support is questionable.

Do not appeal everything. Billing errors belong in corrected claims. COB and eligibility issues need correction. Coding issues should be reviewed by Coding. Appeal when the claim is correct and you have evidence that the payer decision should change.

Payer Submission Methods

Always verify the member product and current denial letter before submitting.

UnitedHealthcare

ONLINE REQUIRED / PREFERRED

Commercial / Medicare Advantage / Medicaid

Online Fax Mail

Reconsideration / Initial Review

Use the UnitedHealthcare Provider Portal or supported API. For most claim-payment disagreements, submit reconsideration first.

Appeal

If reconsideration is upheld, submit the post-service appeal digitally. Beginning February 1, 2026, most network Commercial and Medicare Advantage post-service appeals are required electronically.

Typical Sequence

RECONSIDERATION → APPEAL

Fax / Routing Detail

Do not rely on a general fax number for most network post-service appeals. Use the portal unless the denial notice or plan-specific instructions say otherwise.

Exact rules vary by product, state, network status, and denial type. Peer-to-peer requests may have very short deadlines.

Official payer instructions

Aetna

ONLINE + FAX/MAIL

Commercial / Medicare

Online Fax Mail

Reconsideration / Initial Review

Initial disputes/reconsiderations can be filed through Availity. Aetna may route a request to the correct level if it was submitted as the wrong dispute type.

Appeal

Appeals may be submitted through Availity or by mail/fax using the appropriate Aetna dispute/appeal form and plan instructions.

Typical Sequence

RECONSIDERATION / INITIAL DISPUTE → APPEAL

Fax / Routing Detail

Commercial: 1-859-455-8650. Medicare contracted: 1-860-900-7995. Medicare non-contracted: 1-724-741-4953. Always verify the current denial letter and plan type.

State-specific exceptions and different timelines may apply. Include the denied codes, claim ID, DOS, billed amount, rationale, and supporting records.

Official payer instructions

Humana

AVAILITY ONLINE

Commercial / Medicare Advantage / Medicaid

Online Fax Mail

Reconsideration / Initial Review

Finalized claim disputes and reconsideration-type reviews can be submitted through Availity Essentials using Claim Status → Dispute Claim.

Appeal

Appeals/disputes for finalized Humana Medicare, Medicaid, and commercial claims can be submitted in Availity Essentials. Mail options also exist for some products.

Typical Sequence

CLAIM DISPUTE / RECONSIDERATION → APPEAL AS APPLICABLE

Fax / Routing Detail

The main current provider workflow is Availity or mail rather than a universal provider-appeal fax number.

Do not use the finalized-claim appeal workflow for preauthorization-only disputes or overpayment/PPI disputes. Follow the denial-specific route.

Official payer instructions

Cigna Healthcare

RECON ONLINE / APPEAL WRITTEN

Commercial

Online Fax Mail

Reconsideration / Initial Review

Coding-edit claim reconsiderations can be submitted in CignaforHCP.com or Provider.Evernorth.com when the user has claim/reconsideration access.

Appeal

Provider payment appeals are generally submitted as a written Request for Health Care Provider Payment Review with supporting documentation to the address that applies to the member plan.

Typical Sequence

RECONSIDERATION WHEN AVAILABLE → WRITTEN APPEAL

Fax / Routing Detail

There is not one universal fax for general provider payment appeals on the national provider page. Follow the current form, member ID card, and denial instructions.

Cigna distinguishes routine claim corrections/inquiries from formal appeals. Some services and states have special appeal routes.

Official payer instructions

Regence

AVAILITY REQUIRED FOR MOST APPEALS

Commercial / BlueCard

Online Fax Mail

Reconsideration / Initial Review

Use claim inquiry, pricing-dispute, corrected-claim, or other appropriate workflow first when the issue is not a true appeal.

Appeal

Preauthorization determinations and post-service provider appeals are submitted through the Appeals application in Availity Essentials.

Typical Sequence

RESEARCH CORRECT PATH → AVAILITY APPEAL

Fax / Routing Detail

Key appeal fax lines have been deactivated. Fax is limited to specific exception situations. BCBS FEP appeals are an exception and are not submitted through the standard Availity appeal application.

Pricing disputes are not appeals. Timely filing, duplicate-payment, and additional-information issues may use different workflows.

Official payer instructions

Premera Blue Cross

FAX / MAIL CURRENTLY

Commercial / BlueCard / FEP

Online Fax Mail

Reconsideration / Initial Review

Use corrected-claim or supporting-document workflows when the issue is a billing correction, COB, duplicate, or missing information rather than a true appeal.

Appeal

Use the correct Premera provider appeal form and submit according to the form instructions. The Availity claim-appeal rollout was delayed in July 2026.

Typical Sequence

CORRECT CLAIM WHEN APPROPRIATE → APPEAL FORM IF DISPUTING DECISION

Fax / Routing Detail

Current unified Premera appeals fax: 425-918-5592. Verify the form and plan type before submission.

BlueCard, FEP, HMO, member-authorized appeals, and provider-payment disputes may use different forms. Do not submit an appeal through a generic claim attachment tool.

Official payer instructions

Original Medicare (Fee-for-Service)

MAC-SPECIFIC

Medicare Part A / Part B

Online Fax Mail

Reconsideration / Initial Review

Medicare terminology is different: the first level is a Redetermination by the MAC. The second level is a Reconsideration by a QIC.

Appeal

Submit the first-level redetermination to the MAC that made the initial determination. Most MACs allow electronic submission through their secure portal; written submission is also available.

Typical Sequence

REDETERMINATION → QIC RECONSIDERATION → HIGHER APPEAL LEVELS

Fax / Routing Detail

There is no single national first-level appeal fax. The correct portal, fax, or mailing address depends on the MAC and is shown on the RA/decision or MAC website.

Minor errors/omissions may belong in reopening/correction rather than appeal. First-level redeterminations generally must be filed within 120 days of receipt of the initial determination.

Official payer instructions

TRICARE West (TriWest)

FAX / MAIL FOR CLAIM APPEALS

TRICARE

Online Fax Mail

Reconsideration / Initial Review

TRICARE describes a claim appeal as a request for reconsideration of a claim denial.

Appeal

For West Region claim appeals, submit by fax or mail within the deadline shown on the EOB/notice.

Typical Sequence

CLAIM APPEAL / RECONSIDERATION

Fax / Routing Detail

Claim appeal fax: 866-852-1994. Mail: TRICARE West Appeals, P.O. Box 2130, Virginia Beach, VA 23450.

Authorization appeals use a different route and fax. Follow the denial letter for the exact appeal type.

Official payer instructions

TRICARE East

ONLINE PREFERRED + FAX/MAIL

TRICARE

Online Fax Mail

Reconsideration / Initial Review

Use the appeal route on the denial notice; the process differs by factual versus medical-necessity issues.

Appeal

Humana Military provides an online appeal option and also accepts fax/mail.

Typical Sequence

APPEAL PER DENIAL TYPE

Fax / Routing Detail

Fax: 877-850-1046. Mail: TRICARE East Appeals, P.O. Box 740044, Louisville, KY 40201-7444.

Standard appeal deadlines are generally 90 days from the denial date; expedited appeals have much shorter deadlines.

Official payer instructions

Apple Health / Washington Medicaid

PLAN-SPECIFIC

Medicaid

Online Fax Mail

Reconsideration / Initial Review

If the patient is enrolled in an Apple Health managed care organization, use that MCO's grievance/reconsideration/appeal process first.

Appeal

For managed care, exhaust the MCO appeal system before requesting an HCA administrative hearing when applicable. Fee-for-service/provider hearing rights depend on the notice/remittance and issue.

Typical Sequence

MCO PROCESS FIRST WHEN MANAGED CARE

Fax / Routing Detail

There is no universal provider claim-appeal fax for all Apple Health products. Follow the MCO denial letter or HCA notice.

Molina, UnitedHealthcare Community Plan, Coordinated Care, CHPW, Wellpoint, and other MCOs have their own submission channels.

Official payer instructions

Blue Cross Blue Shield / BlueCard

VARIES BY BLUE PLAN

Commercial / FEP

Online Fax Mail

Reconsideration / Initial Review

There is no single national BCBS reconsideration process. Identify the local/home Blue plan, product, and whether the claim is BlueCard or FEP.

Appeal

Use the appeal process published by the responsible Blue plan. Some plans use Availity, while others require a form, fax, or mail.

Typical Sequence

IDENTIFY RESPONSIBLE BLUE PLAN → FOLLOW PLAN PROCESS

Fax / Routing Detail

Never use a fax number from a different Blue plan. Verify the home/local plan instructions on the EOB, provider portal, or current provider manual.

BlueCard and FEP often have special routing rules. The plan named on the remittance controls the appeal path.

Official payer instructions

Before You Hit Submit

Confirm the claim number, DOS, denied service, CARC/RARC, denial date, filing deadline, exact reason you disagree, supporting records, and the requested outcome. Save the confirmation number, fax confirmation, portal screenshot, or certified-mail proof.

Learn when to appeal

Not Sure if Coding Should Review It?

If payment depends on CPT/HCPCS, diagnosis selection, modifiers, NCCI edits, bundling, code pairs, or documentation-to-code judgment, send it to Coding before changing the claim.

Coding decision guide