Appeal

An appeal is a formal request to a payer to reconsider a denial or underpayment. Effective appeals share five elements: the specific CARC and RARC codes from the EOB, clinical documentation that contradicts the denial rationale, applicable coding guidelines from CPT Assistant or AMA guidance, applicable NCCI edits showing the codes are not bundled (or are bundleable with a modifier), and a clearly stated request for reconsideration submitted on the payer's required form. Most payers offer two to three internal appeal levels plus an external review under the ACA. Each level has its own deadline and missing it forfeits the right to appeal permanently. Common deadlines: Medicare 120 days for redetermination, UnitedHealthcare 180 days for first-level, Aetna 60 days, BCBS varies by state. Per Premier Inc. data, 70% of denials are ultimately overturned when appealed — but per industry surveys, only 35% are ever appealed at all because the labor cost ($25-118 per appeal) exceeds the claim value for many practices. The fix is process: every denial enters an appeal log on day one with the calculated deadline, status checks at day 14, and 48-hour appeal turnaround on every overturnable denial. Distinguishing appealable denials (CO-50 medical necessity, CO-97 bundling with NCCI MI=1, CO-109 not covered) from fixable ones (CO-16 missing information requires a corrected claim, not an appeal) saves weeks of timeline.