Q&A: Appealability of denials

Q: What should organizations consider before appealing a denial? What indicators suggest that an appeal would not be appropriate?

A: Although every denial should be tracked, not every denial should be appealed. Consider the following when determining whether an appeal should be filed:

• The potential for overturning the denial. For instance, if the payer is correct and the denial is valid, it would not be a good use of resources to appeal the denial. Additionally, if the deadline for filing an appeal has passed and there is not a good reason for not having filed an appeal in a timely manner, it may not be a good use of resources to appeal.
• The dollar amount involved in the denial. For instance, if it is a single denial and the cost of the appeal is more than the amount that could be recovered, it may not be a good use of resources to appeal the denial. If the overturning of the denial would not change the overall payment, it would not be a good use of resources. If a payer pays a case rate for a surgery and denies a lab test as not medically necessary, it would not change the payment amount even if the appeal showed that the lab test was medically necessary.

A strong revenue integrity program will have guidelines or policies to determine whether to appeal a denial. Although it may not make good business sense to appeal all denials, all denials should be tracked even if they are not appealed. In the busy world of a business office/billing department, it can be easy for denials to be written off without being tracked or reviewed for the potential of an appeal. This is lost revenue to the organization. The more automated the tracking process is, the less likely something is to be written off before being reviewed for appeal.

Editor’s note: This answer was excerpted from “Four steps to appealing a denial,” in the April 2026 issue of the NAHRI Journal. The NAHRI Journal is a quarterly journal featuring in-depth analysis and expert advice and is an exclusive benefit of NAHRI membership. Not a member? Join today.