Case Management, Appeals, and Denial Management
This final domain covers the work that follows a review: coordinating care across transitions and overturning or preventing denials. Items test the case management process, denial categories, the Medicare appeal ladder, and the content of a persuasive, timely appeal.
Case management process
Standards of practice organize the work as assessment, planning, implementation, coordination, monitoring and evaluation, and outcomes. Core activities include risk stratification and screening, interdisciplinary communication, discharge planning, medication reconciliation, patient advocacy, and attention to social determinants that drive readmissions. Case managers track avoidable days and length-of-stay outliers.
Denial categories
- Technical: eligibility, timely filing, missing authorization, wrong modifier, duplicate claim.
- Clinical/medical necessity: the payer's criteria were not met or not documented.
- DRG or code validation: the payer disagrees with the principal diagnosis, CC/MCC capture, or procedure coding.
The Medicare appeal ladder
- Redetermination by the MAC - file within 120 days.
- Reconsideration by the QIC - 180 days.
- ALJ hearing (OMHA) - 60 days, subject to the annual amount-in-controversy threshold.
- Medicare Appeals Council - 60 days.
- Federal district court - 60 days. Expedited processes exist where the service is urgent. Commercial payers run their own internal and external review levels under state and federal rules.
Building the appeal
State the denial reason in the payer's own words, rebut it point by point, cite the policy and the record evidence that satisfies each element, and ask for the specific relief. Request a peer-to-peer when clinical judgment is disputed. Send the relevant records, not the entire chart.
Worked example
An inpatient stay is denied as observation-appropriate. The reasoning: quote the two-midnight expectation documented at admission, attach the physician's certification, cite the criteria elements met (oxygen requirement, failed outpatient management), and reference the LCD. Filing must beat the redetermination deadline; arguing only that "the physician disagreed" without criteria or record citations usually loses.
Traps that cost marks
- Missing the 120-day redetermination window, which ends the case at level one.
- Sending records without a written argument tied to the denial reason.
- Skipping the peer-to-peer on a purely clinical dispute.
- Confusing a technical denial with a medical necessity denial.