Denial Management and Appeals
Domain 5: Denial Management and Appeals
This domain tests denial classification, root-cause analysis, appeal levels and deadlines, and prevention.
Core rules
- Denial types include eligibility, authorization, coding/bundling, medical necessity, timely filing, duplicate, and COB.
- Work denials by category and value; prioritize high-dollar and recurring denials.
- Medicare appeal ladder: redetermination by the MAC within 120 days, reconsideration by the QIC within 180 days, ALJ hearing within 60 days when the amount threshold is met, Medicare Appeals Council, then federal court.
- Commercial payers set their own levels and deadlines; peer-to-peer review can overturn medical necessity denials.
- Appeal with the medical record, criteria such as MCG or InterQual, a physician letter, and the corrected claim.
- Track denial rate and root cause; fix registration, coding, and authorization processes.
Worked example
An inpatient claim denies as not medically necessary. The record shows the two-midnight rule was met and severity supported admission. Appeal with history, vital signs, failed observation, and physician attestation. If the MAC upholds the denial, request reconsideration within 180 days. Writing off without appeal loses valid revenue and hides the root cause.
Traps
Appealing without reading the denial; missing deadlines; not correcting the claim; failing to document peer-to-peer discussions; treating all denials as clinical.