Claim appeal

An appeal asks the payer to look again, with evidence. It is the right tool when the payer processed the claim and reached a decision you can argue with: a medical necessity denial, a bundling denial where the documentation supports separate services, an authorization denial where the authorization exists, or an underpayment against the contracted rate. Each payer sets its own appeal levels, forms, addresses and deadlines, and many payers distinguish an informal reconsideration from a formal appeal.

Medicare publishes its structure. CMS describes five levels for Part A and Part B claims: a redetermination by the Medicare Administrative Contractor, a reconsideration by a Qualified Independent Contractor, a decision by the Office of Medicare Hearings and Appeals, a review by the Medicare Appeals Council, and judicial review in federal district court. Each level has its own filing deadline, and a late request is dismissed without a look at the merits.

The mistake is appealing what should be corrected and correcting what should be appealed. A CO-16 missing-information denial needs a corrected claim, and an appeal letter about it goes nowhere. A medical necessity denial resent as a corrected claim comes back with the same code and a wasted month. Decide which path each denial takes from its CARC and RARC, write the appeal to the payer’s stated reason, attach the exact records that answer it, and log the date it was sent and the date a response is due.