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Manage claim denials and appeals

Triage a denied claim, work and track an appeal, and close the denial record when the payer renders a final decision.

Before you start

• A claim has been submitted and returned with a denial.
• You have the denial reason code and remittance advice from the payer or ERA.
• You have the biller role, or admin.

Denial appeal status reference

Every denial record carries an appeal status. These are the values Medipyxis tracks, roughly in order from initial triage through final resolution:

Appeal Status	Meaning
Not Started	Denial received; no action taken yet.
Not Appealed	A decision was made not to appeal this denial.
Needs Review	A biller needs to review the denial and decide the response.
In Research	The denial reason is being researched.
Pending Documentation	Waiting on records/documentation to support the appeal.
Pending Provider Input	Waiting on the provider for clinical input.
Ready to Appeal	The appeal is prepared and ready to send.
Appeal Submitted	The appeal has been sent to the payer.
Under Payer Review	The payer is reviewing the appeal.
Additional Info Requested	The payer requested more information.
Appeal Accepted	The payer accepted the appeal for reconsideration.
Appeal Approved	The appeal was approved — the claim should proceed to payment.
Appeal Denied	The appeal was denied by the payer.
Claim Corrected & Resubmitted	The claim was corrected and resubmitted rather than formally appealed.
Closed — No Further Action	Denial closed; nothing further to do.
Closed — Written Off	Denial closed and the balance written off.

Steps — triage a denial

1. Open the Denials view. From the Billing module, open Denials.

The Denials view. The Appeal Status column shows the current stage for each denial. Items in Not Started or Needs Review need attention first.

2. Identify priority denials. Sort by aging to surface the oldest denials first, and filter by Appeal Status to find items that have not been actioned.

3. Open the denial record. Click a denied claim to open the denial detail. Review: - The denial reason code and description from the ERA or payer correspondence. - The original claim's date of service, procedure codes, and diagnosis codes. - Any previous appeal history in the activity log.

4. Set status to Needs Review. This signals to other billers that the denial is being worked.

5. Determine the root cause. Common denial categories and typical responses:

Denial Category	Typical Response
Missing or invalid documentation	Request records; set Pending Documentation
Medical necessity	Gather clinical support; set Pending Provider Input, then Ready to Appeal
Duplicate claim	Verify and void the duplicate; Claim Corrected & Resubmitted or close
Timely filing	Gather proof of timely filing (clearinghouse timestamps); set Ready to Appeal
Coding error	Correct the codes and resubmit; Claim Corrected & Resubmitted
Authorization missing	Obtain retroactive auth if available; otherwise Not Appealed with a note

Steps — work and submit an appeal

6. Gather supporting documentation. Attach the payer's denial EOB/ERA detail, clinical notes supporting medical necessity, and any payer-specific appeal form. Set the status to Pending Documentation while you collect these.

7. Prepare the appeal. Write the appeal narrative in the notes: reference the claim number, date of service, denial reason code, and the clinical or regulatory basis for the appeal. When ready, set the status to Ready to Appeal.

8. Submit the appeal to the payer. Send the appeal package through the payer's channel (portal, fax, or mail) and record the confirmation number in the notes.

9. Set status to Appeal Submitted and record the submission date. Move it to Under Payer Review while you wait, and to Additional Info Requested if the payer asks for more.

Medicare first-level redeterminations must be filed within 120 days of the initial denial; second-level reconsiderations within 180 days. Track these deadlines in the notes — Medipyxis does not currently auto-calculate appeal deadlines.

Steps — track to resolution

10. Record the payer's decision.

    • Approved → set Appeal Approved. The claim should reprocess for payment and post through an ERA.
    • Accepted for review → Appeal Accepted.
    • Denied → Appeal Denied; decide whether a further level of appeal or a correction is warranted.
    • Corrected instead of appealed → Claim Corrected & Resubmitted.

11. Close the denial. When no further action is warranted:

    • Resolved, nothing more to do → Closed — No Further Action.
    • Balance written off → Closed — Written Off.

Result

The denial record reflects the current appeal status and a full activity trail. Closed denials drop out of the active Denials view; use the status filter to include them in reporting.

Do not set a denial to Closed — Written Off without supervisor approval. Write-offs affect your facility's net collection rate and are reviewed in reporting.

Review the Claims Reports in the Reports Center periodically to spot systemic issues — for example, a payer consistently denying a specific modifier — that can be corrected upstream at the coding level.

Troubleshooting

Symptom	Likely cause	What to do
Denial not visible in the Denials view	ERA has not been posted yet	Check the ERA/Payments view; post the ERA first
Appeal Status dropdown is read-only	Your role does not have edit access	Ask your administrator to verify your role permissions
Denial shows Appeal Approved but no ERA payment received	Payer reprocessing is pending	Wait for the next ERA cycle; check the Stedi dashboard for a pending 835

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