> ## Documentation Index
> Fetch the complete documentation index at: https://mso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.
# File appeals
> Appeal levels including Medicare's five-level track, deadlines, the anatomy of an appeal letter, and tracking win rates by payer and reason.
An **appeal** contests a payer's adjudication decision. It differs from a corrected claim: you appeal when the claim was right and the payer was wrong. Appeals have deadlines, levels, and a structure, and the ones that win cite policy rather than expressing frustration.
## Prerequisites
* The denial is genuinely a denial, not a 277CA rejection — see [Submit clean claims](/guides/billing/submit-clean-claims)
* The appeal deadline for this payer, recorded
* The 835 showing the denial
* Supporting documentation assembled
## Know which track you're on
| Type | Track |
| ----------------------------------- | ----------------------------------------------------------------------------------------------------- |
| **Commercial, fully-insured** | Payer's internal levels, then state external review |
| **Commercial, self-funded (ERISA)** | Payer's internal levels under ERISA claims procedure; **state external review generally unavailable** |
| **Medicare FFS** | The five-level federal appeals process |
| **Medicare Advantage** | The plan's process, then the federal MA appeals track |
| **Medicaid FFS** | State fair hearing process |
| **Medicaid MCO** | Plan appeal, then state fair hearing |
**Determine funding status before citing a state statute.** A prompt-pay or external-review argument that doesn't apply to a self-funded ERISA plan weakens an otherwise good appeal. See [Payers vs insurance companies](/concepts/payments/payers-vs-insurance-companies).
Commercial deadlines are set by contract and vary widely — some are as short as 60 or 90 days from the remittance date. Medicare's first level has its own statutory timeframe.
**Record every payer's appeal deadline in your tracking grid** when you sign the contract, not when you need it.
## Medicare's five levels
For Medicare fee-for-service, the appeals process has five sequential levels:1
| Level | Decided by |
| ------------------ | --------------------------------------------------------------------- |
| 1. Redetermination | The MAC |
| 2. Reconsideration | A Qualified Independent Contractor (QIC) |
| 3. Hearing | An Administrative Law Judge (Office of Medicare Hearings and Appeals) |
| 4. Review | The Medicare Appeals Council |
| 5. Judicial review | Federal district court |
Each level has its own filing deadline and, at levels 3 and 5, an amount-in-controversy threshold. Most provider appeals resolve at level 1 or 2. Confirm current deadlines and thresholds with CMS — the amount thresholds are adjusted.
## Anatomy of an appeal letter
Four parts. Keep it to one or two pages.
### 1. Identification
Patient name, member ID, claim number, dates of service, billed amount, denial date, and the **specific CARC and RARC** being appealed. Make it trivially easy for the reviewer to locate the claim.
### 2. The facts
What was done, why, and by whom. Brief and factual. Two or three sentences.
### 3. The argument
**This is where appeals are won or lost.** Cite something:
| Denial type | Cite |
| ----------------- | ------------------------------------------------------------------------------- |
| Medical necessity | The payer's own medical policy, the applicable LCD/NCD, and clinical guidelines |
| Authorization | The authorization number and date, or the payer's own retro-auth policy |
| Timely filing | The clearinghouse acceptance report showing the submission date |
| Coding | The CPT/CDT descriptor, NCCI guidance, and why the modifier applies |
| Eligibility | The **saved 271** showing active coverage on the date of service |
| Non-covered | The plan document or summary of benefits showing coverage |
**Cite the payer's own policy back to them.** An appeal quoting the payer's published medical policy and demonstrating the patient met its stated criteria is far more effective than a clinical narrative alone. Find the policy on the payer's provider site before writing.
### 4. The ask
State it plainly: reprocess and pay the claim at the contracted rate. Include your contact information and any required forms.
### Attachments
Only what supports the argument: the relevant chart notes, the authorization, the eligibility response, the submission proof, the policy excerpt. **Apply minimum necessary** — send what proves the point, not the entire record.
## Steps
Consider the dollar amount, the likelihood of success, and whether it's systematic. A $40 denial may not justify the labor, but two hundred instances of the same $40 denial absolutely does, as one aggregated dispute.
Portal, mail, or fax. Using the wrong channel can mean the appeal is never logged.
Portal confirmation, certified mail receipt, or fax confirmation.
Payer, claim, denial reason, appeal date, level, deadline for the next level, outcome, and days to resolution.
Note the next deadline immediately — it runs from the denial of the prior level.
## Track win rates
Appeal outcomes are management information:
| Metric | Tells you |
| ----------------------------------- | ----------------------------------------- |
| Overturn rate **by payer** | Which payers deny claims they shouldn't |
| Overturn rate **by denial reason** | Which appeals are worth filing |
| Average days to resolution by payer | Cash flow planning |
| Appeals filed vs denials eligible | Whether you're leaving money on the table |
A payer with a high overturn rate is denying claims it should have paid. That is a pattern worth raising in contract renegotiation, and in some states worth raising with the regulator.
## Systematic denials get a different treatment
When the same denial recurs across many claims, don't file dozens of individual appeals. **Aggregate it**: one letter identifying the pattern, the claim list, and the systematic cause, usually a payer configuration error or a policy misapplication. Payers correct configuration errors when shown the pattern, and the correction is retroactive across every affected claim.
## Verify it worked
* [ ] Payer funding status determined before choosing the argument
* [ ] Appeal deadline recorded for every payer contract
* [ ] Letters cite payer policy, LCD/NCD, or documentary evidence
* [ ] Correct form and channel used
* [ ] Submission proof retained
* [ ] Every appeal logged with outcome and days to resolution
* [ ] Win rates tracked by payer and reason
* [ ] Systematic denials aggregated rather than appealed individually
## Common failure modes
| Failure | Consequence |
| ------------------------------------------- | -------------------------------------------------- |
| Appealing a 277CA rejection | Nothing to appeal; the claim was never adjudicated |
| Missing the deadline | Unrecoverable |
| No policy citation | Low overturn rate |
| Citing state law against a self-funded plan | Undermines the argument |
| Wrong form or channel | Appeal never logged |
| Sending the entire record | Over-disclosure of PHI |
| Not tracking outcomes | No idea which appeals are worth filing |
| Filing individually on systematic denials | Enormous labor for the same result |
## Sources
1. CMS, [Medicare Parts A & B Appeals Process](https://www.cms.gov/medicare/appeals-grievances/fee-for-service). Confirm current deadlines and amount-in-controversy thresholds.
## Related topics
- [Work the denial queue](/guides/billing/work-the-denial-queue.md)
- [Beat timely filing limits](/guides/billing/beat-timely-filing.md)
- [Respond to payer audits and record requests](/guides/compliance/respond-to-payer-audits.md)
- [Claim denials, explained](/concepts/payments/claim-denials.md)
- [Payers vs insurance companies (they're not synonyms)](/concepts/payments/payers-vs-insurance-companies.md)
- [Denial code playbook](/reference/edi/denial-code-playbook.md)
- [Timely filing limits by payer](/reference/payers/timely-filing-limits.md)