File an appeal

Outcome

A formal appeal letter (with all required attachments) is delivered to the payer through their preferred channel, the denial is moved to APPEALED, the case is on the followup calendar, and the audit log carries the full chain.

Prerequisites

Scope	What it lets you do
billing.denial.read	Open denials
billing.appeal.write	Compose and submit an appeal
clinical.documents.read	Attach clinical records

A denial in status OPEN or IN_PROGRESS whose CARC the platform has classified as appeal-eligible. Some CARCs (e.g. CO-1/CO-2 patient liability) are not appealable; the File appeal button greys out for those with a tooltip explaining why.

When to appeal vs. when not to

Steps

1. Open the denial at /denials/:id. Click File appeal.

2. Pick the appeal template from the dropdown. Templates are payer- specific where the payer has a published appeal format; otherwise the generic letter template is used. Each template carries the required sections (member info, claim info, reason for appeal, supporting documentation list).

3. Compose the body. The editor pre-fills:

   • Member identifiers.
   • Claim identifiers (control number, original DOS).
   • The CARC + RARC the payer cited.
   • Your appeal reason from a checklist of common reasons (e.g. "service was authorized", "modifier was correct per state rule X.Y", "untimely reasonable cause").
   • A free-text addendum.

4. Attach supporting documents:

   Attachment	Source
   Clinical records	Member's Documents tab.
   Authorization confirmation	/authorizations/:id → Print to PDF.
   Original 837	Claim → Submission tab → Download.
   EOB scan / payer correspondence	Denial → Documents tab.
   State-rule citation	Pasted into the body or attached as PDF.

   The platform validates attachments against the template's required-list; missing required attachments block submission.

5. Pick the delivery channel:

   Channel	When
   Payer portal	Most common. The platform pre-fills the portal's known fields and downloads the packet for upload.
   EDI 276/277 inquiry + appeal payload	Where the payer accepts electronic appeals.
   Mail / fax	Where required. The platform generates the print packet with cover sheet and barcode.

6. Click Submit. The platform:

   • Moves the denial to APPEALED.
   • Records the submission with channel, timestamp, and packet digest.
   • Sets a default followup date based on the payer's published appeal decision SLA (or 30 days if unknown).
   • Optionally sends a confirmation email to the responsible biller.

Mass appeal

Where many denials share the same root cause (e.g. a payer's incorrect modifier rule for one month):

1. Filter the denials worklist to the affected set.

2. Select all → Mass appeal. Pick the template; the body and attachments use the per-row context. The packet ships as one bundle per denial — no payer wants a single appeal covering many claims.

3. Confirm the bulk preview. The dialog shows row count, attachment count, and any rows that would fail validation; reject or remove those before continuing.

Validation

Check	Expected
Denial status = APPEALED	Yes, immediately after submit.
Communication tab carries an appeal entry with packet digest	Yes.
Audit log carries an appeal.submit row	Yes.
Followup date set	Yes; visible on the denials worklist as a deadline indicator.

Troubleshooting

Symptom	Cause	Fix
File appeal greyed	CARC not classified appeal-eligible	Confirm via 8.3 — CARC/RARC; if you believe the CARC should be appealable for your contract, edit the appeal_eligibility rule in the engine (5.3).
Submission blocked: "missing required attachment"	Template requires a doc you haven't attached	Add the doc; the validation panel lists exactly what is missing.
Payer rejects appeal as untimely	Submitted past the appeal window	If your contract permits late-filing, file a late-filing appeal with reasonable-cause; otherwise write off.
Followup fires but no payer response	Payer SLA missed	Open the appeal → click Escalate; the platform composes a follow-up letter referencing the original.

Next

2.6 — Run a timely-filing report