An appeal asks a payer to review its decision to deny or underpay a claim, usually with a letter and supporting documentation. Payers have appeal deadlines and often several levels of appeal, ending in external review.
Appeals are for claims that were correct. If the claim itself had an error, a corrected claim is faster.
Related terms
- Claim denial
- A payer's decision not to pay a claim that it received and processed.
- CARC (claim adjustment reason code)
- The standard code that explains why a claim line was paid differently than billed.
- Medical necessity
- The requirement that a service is reasonable and needed for the patient's condition.