What is a claim appeal?
An appeal asks the payer to reconsider a denial or reduced payment, with an argument and evidence. Each payer has levels and deadlines, and Medicare has five levels.
Medicare appeal levels
| Level | Decided by | File within |
|---|---|---|
| 1. Redetermination | The Medicare Administrative Contractor | 120 days of the initial decision |
| 2. Reconsideration | A Qualified Independent Contractor | 180 days of the redetermination |
| 3. Hearing | An Administrative Law Judge | 60 days, above a minimum amount |
| 4. Review | The Medicare Appeals Council | 60 days |
| 5. Judicial review | Federal district court | 60 days, above a minimum amount |
- Commercial plans set their own levels, usually one or two internal appeals followed by an external review.
An appeal says the payer got it wrong and shows why. It’s the right path when the claim was correct and the payer’s decision wasn’t; when the claim had an error, a corrected claim is faster.
What makes an appeal work
- The right level and deadline, from the payer’s rules. Late appeals are dismissed without being read.
- A specific argument. For a medical necessity denial, quote the payer’s policy and answer each criterion with the note, result or order that meets it.
- Only the evidence that matters, organized so a reviewer can find it: a cover letter, an index and numbered pages.
- The payer’s form, when it has one.
Why so few denials are appealed
Building a good appeal takes time: pulling records, reading the policy, writing the letter, assembling the packet. When teams are short on time, appeals happen only for large claims, and the rest of the denied money is written off.
Run your revenue cycle as workflows.
We are working with a small group of billing and operations teams to shape worklist. Tell us where your work gets stuck, and we'll show you how it would run.