What we do
Claims support & appeals
The part of this job that does not pay a commission and matters most. When a claim is denied, a bill looks wrong, or a prior authorisation stalls, you have someone to call.
What you get
Concrete things, not a conversation about a conversation.
Every one of these is included, and none of it is billed to you. Our compensation comes from the carrier you eventually choose — or from nowhere at all, if the right answer is to leave your coverage exactly as it is.
- A plain-English read of the Explanation of Benefits or denial notice
- Identification of what actually went wrong — coding, authorisation, network or coverage
- The specific documents your provider needs to supply, and to whom
- The applicable appeal level, deadline and route
- Help preparing and filing the appeal, and following it up
- Escalation to the carrier’s broker channel where that moves things faster
How it runs
Step by step.
- 01
Send us the paperwork
The Explanation of Benefits, the denial letter, and the bill. Most of what we need to diagnose the problem is on those pages, in language designed not to be read.
- 02
Find the actual cause
A surprising share of denials are administrative — a wrong code, a missing modifier, an authorisation that was obtained but not attached, a provider billed as out-of-network in error.
- 03
Fix or appeal
Administrative problems get corrected and rebilled. Genuine coverage disputes go through the formal appeal levels, with the medical necessity documentation your prescriber or provider needs to supply.
- 04
Follow it through
Appeals have deadlines on both sides and stall without pressure. We track dates, chase the carrier, and tell you honestly when a case is not winnable so you can stop spending energy on it.
The most common reasons a claim gets denied
| Reason | What it usually means | Typical fix |
|---|---|---|
| Coding error | The procedure or diagnosis code does not support the service | Provider corrects and rebills |
| Missing prior authorisation | Approval was required and not obtained or not attached | Retro-authorisation or appeal with clinical notes |
| Out-of-network provider | A facility or an assistant was outside the network | Network gap exception or negotiated adjustment |
| Not medically necessary | The carrier disputes 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 — we will say so |
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 rather than because a novel argument was made. The work is in the assembly, and the deadlines are unforgiving.
The deadlines that decide the outcome
Appeal rights are generous in Medicare and they are also strictly timed. Deadlines run from the date printed on the denial notice, not from the date you opened the envelope.
| Level | Who decides | Typical timing |
|---|---|---|
| Reconsideration | The plan itself | Weeks; expedited cases far faster |
| Independent review | An independent review entity | Weeks |
| Administrative law judge | An ALJ hearing | Months |
| Further review | Appeals council, then federal court | Longer, and rarely needed |
What you can do yourself, before calling anyone
If any of that stalls, send us the paperwork. We escalate through the carrier’s broker channel, which is frequently faster than the member line, and we will tell you honestly when a case is not winnable so you can stop spending energy on it.
- Find the Explanation of Benefits and the denial letter, and read the stated reason.
- Call the provider’s billing office and ask whether the claim was coded and submitted correctly — a large share of denials are fixed here without any appeal.
- Check whether prior authorisation was required, and whether it was obtained.
- Ask the plan, in writing, for the specific policy provision the denial relies on.
- If it is a drug denial, ask your prescriber whether they will support an exception request.
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.
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. Call and ask.
How long do appeals take?
Standard reconsiderations are typically resolved within weeks. Expedited appeals, available when waiting would seriously jeopardise your health, are much faster — often within 72 hours. Later levels take considerably longer. We will tell you which route applies to your situation.
Coverage involved
The products this service touches.
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Medicare Advantage (Part C)
Medicare Advantage (Part C) is a private plan that replaces how you receive your Part A and Part B benefits. Plans usually bundle prescription drug coverage and extras like dental and vision, often carry a $0 monthly premium, and cap your annual out-of-pocket costs — but you use a provider network and pay copays at the point of care.
About this coverage -
Part D prescription drug plans
Medicare Part D is prescription drug coverage sold by private carriers, either as a standalone plan alongside Original Medicare and a Medigap policy or bundled inside a Medicare Advantage plan. Each plan has its own formulary, tiers and pharmacy network, and an annual cap on what you pay out of pocket for covered drugs.
About this coverage -
Medicare Supplement (Medigap)
A Medicare Supplement, or Medigap, is a private policy that pays the deductibles, copayments and coinsurance Original Medicare does not. You keep Original Medicare, see any provider in the country who accepts Medicare, need no referrals, and pay a monthly premium. Prescription drug coverage is bought separately as a Part D plan.
About this coverage -
ACA / Marketplace health plans
An ACA Marketplace plan is individual major-medical health insurance sold under the Affordable Care Act. Carriers cannot decline you or price you on health history, every plan covers the ten essential health benefits, and households under certain income levels receive a premium tax credit that reduces the monthly cost — often substantially.
About this coverage