A denial letter is designed to look final. It is not. It is the opening move in a defined process with defined deadlines, and a large share of denials are reversed once someone assembles the right paperwork.
Here is what to do, in order.
First: write down the date
Appeal deadlines run from the date on the denial notice, they are shorter than people expect, and a missed deadline usually ends the matter regardless of the merits.
Before anything else, note the date and put the deadline in your calendar. Everything below is easier when you are not doing it in the last three days.
Second: work out what actually went wrong
Most denials are not coverage disputes at all. They are administrative.
| What the letter says | What it usually means | What normally fixes it |
|---|---|---|
| Coding error | The procedure or diagnosis code does not support the service billed | Provider corrects and rebills |
| No prior authorization | Approval was required and not obtained, or obtained and not attached | Retro-authorization, or appeal with clinical notes |
| Out-of-network provider | A facility, lab or assisting clinician sat outside the network | Network gap exception or negotiated adjustment |
| Not medically necessary | The carrier disputes the clinical justification | Appeal with prescriber documentation |
| Step therapy not met | A required first-line drug was not tried | Exception request with clinical rationale |
| Service excluded | The plan genuinely does not cover it | Usually not appealable — and we will say so |
Only the last row is a dead end. The rest are process problems with process solutions.
Third: gather three documents
- The Explanation of Benefits
- The denial letter itself
- The bill from the provider
Almost everything needed to diagnose the problem is on those pages, written in language designed not to be read.
The appeal levels, briefly
Medicare appeals proceed through defined levels, each with its own deadline.
A Medicare Advantage or Part D denial starts with a reconsideration by the plan itself, then moves to an independent review entity, then to an administrative law judge, and further if the amount in dispute justifies it. Original Medicare follows a parallel structure through the claims contractor.
Most successful appeals end at the first or second level. And most of them succeed because the clinical documentation was assembled properly — not because a clever argument was made. The work is in the assembly.
Ask for an expedited appeal when timing matters
If waiting for a standard decision would seriously jeopardize your health or your ability to regain function, you can request an expedited appeal. Those are decided far faster — often within 72 hours rather than weeks.
Say the words explicitly when you call, and have your prescriber say them too.
The one that is not a denial at all
Worth naming because it catches people every year: observation status.
You can spend two nights in a hospital bed and never be formally admitted, because you were classified as under observation — technically outpatient care. That changes which part of Medicare pays, changes your cost sharing, and can affect whether a subsequent skilled nursing stay is covered at all.
If you are in a hospital bed, ask directly whether you are admitted or under observation. Ask more than once, and ask again if the answer changes.
What we do
Claims support is the part of this job that pays no commission and matters most. For our clients we:
- Read the Explanation of Benefits and translate it
- Identify what actually went wrong — coding, authorization, network or coverage
- Tell you exactly what your provider needs to supply, and to whom
- Confirm the applicable appeal level, deadline and route
- Help prepare and file the appeal, and chase it
- Escalate through the carrier’s broker channel where that moves things faster
- Tell you honestly when a case is not winnable, so you can stop spending energy on it
That last point matters. Not every denial is worth fighting, and being told so early is worth something.
Send us the letter
If you are a client, forward the denial as soon as it arrives — the deadline is already running. If you are not, call anyway and we will at least make sure you are pointed at the right process before the clock runs out.
There is no charge either way.
Frequently asked questions
Do you charge for claims help?
No. It is part of what a broker relationship is for. We are compensated by the carrier on the enrollment, and helping when something goes wrong afterwards is the part of the arrangement that actually earns it.
How long do Medicare appeals take?
Standard reconsiderations are typically resolved within weeks. Expedited appeals, available when waiting would seriously jeopardize your health, are much faster — often within 72 hours. Later levels take considerably longer.
I did not enroll through you. Can you still help?
We help our own clients as a matter of course. If you are not a client we will still point you at the right process and the right deadline, and if we are appointed with your carrier we can often do more than that.