Claim Appeal Process
Definition
A claim appeal is a formal request to the payer to reconsider a denied claim. The provider submits additional documentation — clinical notes, medical records, peer-reviewed literature — to demonstrate the service was medically necessary and correctly coded. 70-80% of appealed denials are overturned, yet 47% of denials are never appealed. Each unworked denial represents lost revenue averaging $57.23 in rework costs.
Why Appeals Matter
Appeals are the last line of defense against revenue loss. Medicare allows 120 days for redetermination at the MAC level. Commercial payers set their own deadlines: UnitedHealthcare allows 60 days, Anthem 365 days, Aetna 180 days. Missing the appeal deadline converts a recoverable denial into permanent revenue loss. See claim denial appeal rules.
How Appeals Work
Level 1: Internal appeal to the payer with supporting documentation. Level 2: Second-level internal appeal (different reviewer). Level 3: External review by an independent reviewer. Medicare uses a 5-level appeal process: redetermination, reconsideration (QIC), ALJ hearing, Medicare Appeals Council, federal court. Each level has its own deadline and documentation requirements.
Related Terms
Claim denial — what triggers the appeal. CARC code — explains the denial reason. Medical necessity — the most common appeal basis. Remittance advice — contains the denial details needed for the appeal.
Common Questions
How long do I have to file an appeal?
It depends on the payer. Medicare: 120 days for redetermination. UHC: 60 days. Anthem: 365 days. Aetna: 180 days. Cigna: 180 days. Always check the remittance advice for the specific appeal deadline and follow the payer's submission instructions exactly.
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This glossary is for informational purposes. Consult official billing guidelines and payer policies for definitive definitions. Last updated: 2026-04-06.