Health and Wellness

The Appeals Process in Medical Billing

Medical billing can be complex. It involves many steps and different people. To get paid on time and correctly, you have to follow specific stages. Good medical billing is crucial for hospitals, labs, and practices. In this blog, we look into the appeals process. We’ll also discuss how to create a strong medical billing system. This system makes sure your appeals are handled fast and accurately. It helps in building a strong revenue system.

Appeals Process In Medical Billing


Medical billing specialists have a key role. That’s why most physicians have a tendency to outsource the financial management of the practice to the best medical billing company in the USA. This is because they know what each patient has to pay, check their insurance, fill out correct billing forms, and get the payment from insurance or patients. This happens from the time a patient sets up a doctor’s appointment until they get paid by the insurance or patients.

Why Do Claims Not Get Reimbursement?


When a healthcare provider doesn’t get paid for a service, they can use the medical billing appeals process. This happens when the insurance company or the patient disagrees with a charge. Here are some reasons why a claim might get denied:


  • The patient isn’t part of the insurance plan.
  • The insurance doesn’t cover the specific medical procedure or treatment.
  • The ambulatory surgical center (ASC) didn’t get approval before providing services.
  • There isn’t enough proof to support why the medical procedure was done.
  • There’s no valid referral number.
  • Mistakes in the claim details, like using the wrong procedure code for the patient’s age.
  • Not enough supporting documents were sent with the claim.


Healthcare offices need to appeal denied claims to get the money and avoid audits. If they don’t appeal, auditors might think there are compliance problems or billing mistakes that the providers are not fixing.

Appealing Denied Claims: Simple Steps for Healthcare Providers


Want to improve your chances of getting paid when a claim is denied? Here’s what you can do:

  • Call the Insurance Company: Sometimes, denial codes don’t explain why a claim was denied. Call the insurance company to find out.
  • Record Important Information: When you call, note the date, and the representative’s name, and get a reference number. This helps speed up the process.
  • Use the Correct Claim Number: Make sure to use the correct claim number on a corrected claim to avoid errors.
  • Plan Your Appeals: Focus on appealing high-dollar claims. Not every denial needs an appeal, so have a strategy.
  • Categorize Denials: Identify patterns by categorizing denials. This helps streamline the appeals process and guides your approach.
  • Write Appeals Letters: Use standard appeal letters for common denials. For unique cases, create custom appeal letters with all the necessary details.
  • Include Relevant Documentation: Only include specific documentation related to the claim to avoid complications and save time.
  • Get Professional Help: Consider hiring a professional reviewer or a physician with billing experience to oversee the appeals process.
  • Create a Contact List: Keep a list of contacts for different payers, especially the denials manager. Avoid using someone from accounts receivable.
  • Organize with a Spreadsheet: Create a spreadsheet with details for each appeal, including submission dates and payer requirements.
  • Follow-Up Monthly: Set reminders to follow up on each claim monthly to avoid any falling through the cracks.
  • Map Out the Appeal Steps: Clearly map out the steps of the appeal process, from calling the payer for clarification to considering legal action if needed.

Following these steps simplifies the appeals process and improves your chances of getting the claims paid.

Claim Resubmission Basics


If a claim is rejected initially because of missing details or coding errors, it can be resubmitted with the correct information. When handling claim resubmissions, the billing team needs to provide:


  • An updated copy of the claim and a duplicate of the original one
  • A copy of the remittance advice that shows the denial or incorrect payment
  • Any documents needed by the insurance company
  • Clearly label each claim as a ‘resubmission.


Effective communication is crucial for successful medical billing, especially in the appeals process. It begins with understanding your payer systems and requirements. Then, you work with patients to grasp their financial responsibilities and coverage details. Your team diligently ensures that appeals don’t get lost in paperwork. Throughout, various details matter: tracking, filing requirements, payment statuses, and consistent follow-up. If time or resources are limited, consider partnering with a Revenue Cycle Management (RCM) provider to strengthen this vital aspect of your RCM lifecycle.



What is a medical appeal?

An appeal is another review of your case by your insurance company. Appeals must be made in writing. Your insurance company will notify you of your appeal rights when you receive your notice of denial.

What’s the gap between appeal and reconsideration?

Appeals usually go to a different group, like an unbiased independent review organization (IRO). Reconsiderations, on the flip side, often get looked at by the same payer who said no to the claim at the start.

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