File an appeal

Outcome

A denial that warrants challenge has a clean appeal package — letter, documentation, prior records — submitted to the payer through the platform's appeal flow, with the denial advanced to APPEAL_PENDING and a follow-up date set.

Prerequisites

Scope	What it lets you do
billing.denial.read	Read the denial
billing.denial.appeal	Submit appeals
billing.denial.write	Update denial state

A clear understanding of the payer's appeal window (typically 30, 60, 90, or 180 days from denial date — see your contract / payer config).

When to appeal

The CARC list at 5.2 tells you which are typically appealable. As a rough guide:

CARC	Appealable?
CO-15 (auth invalid)	Yes if you have auth documentation.
CO-29 (timely filing)	Yes with timely-filing exception evidence.
CO-50 / CO-96 (non-covered)	Sometimes; depends on payer policy.
CO-167 (dx not covered)	Sometimes with medical-necessity letter.
PI-50 (medical necessity)	Often; documentation-driven.
CO-45 (fee-schedule diff)	Rarely (it's contractual).
CO-97 (bundled)	Rarely; usually re-code instead.

Steps

1. Open the denial. Click File appeal. The button is greyed if the CARC isn't appealable, the appeal window has passed, or you lack scope.

2. Choose the appeal level:

   Level	Use
   Reconsideration / first-level	Default; payer reviews.
   Second-level	After a denied first-level.
   External review	After exhausted internal levels (state-specific).

3. Pick or compose the appeal letter. The platform offers payer- specific templates with auto-filled fields (member, claim ID, CARC, denied amount, dates). You edit any field; the audit row stamps your final wording.

4. Attach documentation. Drag-drop:

   • Original 835 / EOB.
   • Auth (if disputing CO-15 / CO-197).
   • Medical-necessity letter (if PI-50, CO-167).
   • Original chart note / order (if disputing fact).
   • Prior payer's EOB (if COB-related).

5. Submit. The platform packages and sends per the payer's accepted channel:

   Channel	Effect
   Payer portal	Submitted via portal API; tracking ID returned.
   Mail / fax	Generates PDF + cover sheet; you mail or fax outside the system.
   837 corrected claim	For payers that accept appeals as resubmission with frequency 7.

6. Set follow-up. The denial flips to APPEAL_PENDING; set a follow-up date based on the payer's response SLA (commonly 30-60 days). The worklist surfaces overdue follow-ups in red.

What happens after submission

The platform watches incoming 835s for a reversal of the original denial; when it sees one (CR group adjustments referencing the original), the denial auto-flips to RESOLVED with the appeal credited.

Bulk appeals

Pattern denials (a stack of CO-15 for the same payer with the same auth issue) can appeal as a batch:

1. Filter denials to the pattern.

2. Bulk select, Mass appeal. One template; one cover sheet per denial; one combined documentation set if your tenant allows.

3. Submit. Each gets its own audit row; the bulk batch ID lives on each denial.

Validation

Check	Expected
Denial flips to APPEAL_PENDING	Yes.
Audit log captures actor + final letter + attachments	Yes.
Follow-up date sticks	Yes.
Auto-flip to RESOLVED when CR reverses arrive	Yes; verify on Communication tab.

Troubleshooting

Symptom	Cause	Fix
File appeal greyed	CARC not appealable, window expired, or scope missing	Hover the button; tooltip names the gate.
Submission fails with portal API 4xx	Payer credentials expired or portal change	Tenant Manual → Trading partners → Test connection.
Auto-flip didn't happen on a clear reversal	CR reference logic missed it	Manually flip to RESOLVED with note; ping support.
Bulk appeal looks at the wrong attachments	Attachments are per-denial; bulk uses one common set	Re-do as one-by-one; bulk is best for true pattern packets.

Where to next

• 5.6 — Write off with reason — when an appeal won't help.
• 6.5 — Follow-up cadence — managing follow-up dates across the team.