Denial appeals: how to control and recover amounts

The denial appeal exists because the denial came first. In an ideal scenario, this task would be unnecessary: procedures would be recorded correctly, claims would be submitted without discrepancies and payers would pay in full.

In practice, however, denials happen, and when they do, the appeal is no longer a choice. Skipping this stage means accepting financial losses that, in many cases, could be reversed.

The real strategy starts earlier: in the quality of clinical documentation, in the correct coding of procedures and in internal audit processes. A well-executed appeal comes afterward, as a response to what prevention could not avoid.

What is a medical or hospital denial appeal?

A denial appeal is the formal dispute process through which hospitals and clinics challenge a payment refusal by health plans. When a payer applies a denial (that is, refuses full or partial payment for a procedure), the institution has the right to present technical and documentary arguments to reverse that decision.

The mechanism is regulated by Brazil’s National Supplementary Health Agency (ANS) and is the formal channel for technical dialogue between providers and payers. The goal is to ensure that procedures performed appropriately are properly paid for.

A practical example: the hospital performs emergency surgery on a patient, but the health plan refuses payment, claiming there was no prior authorization. Through the denial appeal, it is possible to show that it was a medical emergency, a situation in which the law does not require prior authorization.

How does the denial appeal process work?

The process follows well-defined steps that must be respected to ensure the payer reviews it properly:

1. Denial identification: the billing team maps which procedures were refused on the payment statement sent by the health plan.

2. Technical review: specialized professionals assess whether the denial is justified or whether there are valid arguments for an appeal.

3. Documentation preparation: gathering the medical records, medical reports and technical opinions that support the appeal.

4. Formal filing: submitting the appeal within the deadline set by the payer, generally 30 to 60 days after the denial is received.

5. Follow-up: monitoring progress until the payer’s final response is received.

When can a denial appeal be filed?

Some situations are consistently more likely to be reversed. Knowing them makes it possible to prioritize the billing team’s efforts:

• Administrative denials due to correctable failures:when the refusal stems from a filling error or a missing document that can be resubmitted.

• Urgent and emergency procedures:Law No. 9,656/98, which regulates health plans in Brazil, guarantees immediate coverage in life-threatening situations, regardless of prior authorization.

• Clear contractual coverage:when the health plan refuses a procedure explicitly covered by the contract or by current legislation.

• Coding discrepancies: when there is disagreement over the TUSS code assigned to the procedure performed.

• Outdated clinical guidelines:when the payer uses superseded medical protocols to refuse procedures widely accepted in the scientific literature.

On the other hand, some cases have little chance of being reversed and may not be worth the investment of time and resources: procedures outside contracted coverage without legal support, clinical documentation insufficient to prove medical necessity, or denials already upheld at a previous level on solid technical grounds.

How to prepare a denial appeal

The quality of the documentation is the main success factor. A well-structured appeal needs to bring together:

• Complete medical record:with progress notes, prescriptions and all the records that justify the procedure.

• Reports and technical opinions:documents that prove the clinical indication and the need for the treatment.

• Up-to-date protocols and guidelines:scientific references that support the medical course of action taken.

• Applicable legislation: citation of the ANS regulations and federal laws that support the case.

The appeal should follow a clear structure: identification of the patient and the form, detailed technical grounds, legal basis, an organized list of attached documents and an objective request for reversal stating the amount disputed.

Deadline and regulatory basis

ANS Normative Resolution No. 503/2022, which regulates written contracts between health plans and service providers, requires contracts to expressly set out the cases for denial, the deadlines for the provider to appeal and the deadlines for the payer to respond.

The regulation also guarantees that the provider has access to the reasons for denials and the right to challenge them. One important point: the agreed appeal deadline must be identical to the payer’s response deadline, which ensures parity between the parties.

Main reasons for denials and how to appeal each one

How to implement denial appeal control

An organized control system increases the reversal rate and reduces the team’s rework. The essential elements are:

• Centralized log: a spreadsheet or system with all appeals filed, response deadlines and updated status.

• Defined responsibilities: each stage of the process, from identifying the denial to following up on the appeal, must have a clear owner.

• Deadline alerts: automatic reminders so filing and follow-up windows are not missed.

• Structured archive: documentation for each appeal organized by payer, period and type of denial.

Indicators to monitor

Four metrics are central to assessing the maturity of the process:

1. Reversal rate: percentage of denials reversed out of the total number of appeals filed.

2. Amount recovered per period: the financial amount recovered monthly or quarterly.

3. Average response time: how long each payer takes to review appeals.

4. Main reasons for refusal: a ranking of the most frequent types of denial, the basis for preventive actions.

Practical cases of successful appeals

Case 1: Emergency surgery without prior authorization

A patient arrived at the emergency room with acute appendicitis. The payer denied the claim for lack of authorization. The appeal presented the complete medical record showing the emergency, cited the legislation that waives prior authorization in emergencies and included a medical opinion on the risks of postponement. Result: denial fully reversed in the first negotiation.

Case 2: Additional tests during a hospital stay

During a post-surgical hospital stay, the patient developed complications that required a CT scan and additional lab tests. The health plan refused payment, considering the tests excessive. The appeal documented the clinical course that justified each request and presented protocols from the specialty society. Result: 80% of the denied amount recovered after technical review.

Case 3: Specialized surgical material

An orthopedic surgery with a specific prosthesis was denied because the prosthesis was not on the payer’s standard list. The appeal demonstrated ANS coverage for the material, included the surgeon’s opinion on the specifics of the case and presented a technical comparison with the available alternatives. Result: denial reversed after a second‑level appeal.

Well-managed denial appeals reduce losses and strengthen cash

Structured management of denial appeals is one of the most direct levers on hospital revenue. Every well-grounded appeal recovers amounts already invested in patient care and strengthens the hospital’s position with payers.

With Rivio’s AI platform, it is possible to automate critical stages of this cycle: from medical audit to XML submission, including generating and following up on denial appeals after the payers’ review. The solution identifies discrepancies, prevents invisible losses and makes sure the hospital receives the full amount it is entitled to. Rivio contractually commits to reimbursing the hospital 100% if a denial is not reversed.

FAQ – frequently asked questions about denial appeals

What is the deadline for filing a denial appeal?

The deadline varies by payer, but it generally ranges from 30 to 60 days from receipt of the payment statement with the denials. ANS Normative Resolution No. 428/2017, which regulates authorization and refusal processes between providers and payers, sets the minimum parameters that must be respected. The specific deadline in the contract with each payer needs to be checked.

Which documents are essential in an appeal?

A complete medical record, reports and technical opinions, up-to-date clinical protocols, applicable legislation and any record that proves the need for the procedure performed.

Is it possible to appeal a denial already upheld at the first level?

Yes. If the payer maintains the refusal, a second-level appeal can be filed. If the refusal persists, the provider can turn to the ANS independent audit or pursue other administrative and legal avenues.

How do you calculate whether an appeal is worth it?

Consider the amount denied, the likelihood of reversal based on the type of denial and the documentation available, and the estimated cost of the team’s time to prepare the appeal. As a reference, a healthy process should recover at least three reais for every real invested in the appeal.

How can the success rate of appeals be improved?

Invest in training the billing team, improve the quality of clinical documentation in medical records, keep protocols up to date and implement internal claim audits before submission to payers.