APPEAL PLAYBOOKS
Structured procedures by denial category — corpus-backed overturn rates
4 PLAYBOOKS
PA-001
Prior Authorization Missing
Denial based on missing, expired, or incorrect prior authorization
80.0%
Corpus Overturn Rate
N=15
Precedents
When to use
Denial reason code indicates PA not obtained, PA expired before service, wrong PA number, or PA issued for incorrect service code. Highest-yield category in the corpus — appeal every PA denial regardless of payer.
Required documentation
Original PA request (with date)
PA confirmation / reference number
Clinical summary (progress notes, treatment plan)
Treating clinician attestation
LOCUS/GAF scores (if BH)
Service date confirmation
Appeal steps
01
Pull the PA request record
Retrieve the original PA request with timestamp. If PA was obtained but not logged by payer, this is the primary evidence — attach payer confirmation number and the date the PA was issued.
02
Write a structured appeal letter
Lead with the PA reference number and issuance date. State clearly that authorization was obtained prior to service. Attach clinical summary demonstrating medical necessity was met at time of PA request.
03
Attach clinical narrative with LOCUS/GAF
Behavioral health prior auth denials reversed at 80%+ when clinical documentation is complete. Include LOCUS score, GAF, and progress notes supporting the level of care authorized.
04
Cite MHPAEA if applicable
If payer applies more restrictive PA requirements to BH services than comparable medical/surgical services, cite MHPAEA parity violation. This applies to UHC, BCBS, Cigna, and Anthem in particular.
05
File within 30-day window
Most payers enforce 30-day internal appeal deadlines. Log the deadline at time of denial receipt. File earlier if possible — late appeals are administratively rejected without review.
Applicable payers
ENR-001
Enrollment Issue
Denial based on patient enrollment status, eligibility gaps, or plan administrative errors
61.9%
Corpus Overturn Rate
N=21
Precedents
When to use
Denial reason: "patient not enrolled," "coverage terminated," "enrollment lag," or "inactive member." Highest-N category in the corpus. Often an administrative error on the payer side — eligibility verification is the first step before drafting the appeal.
Required documentation
Eligibility verification screenshot (at date of service)
Employer enrollment confirmation
Insurance card copy (front/back)
Enrollment effective date documentation
EOB showing prior claims paid (if applicable)
Appeal steps
01
Verify eligibility at time of service (not at time of filing)
Pull eligibility verification records as of the date of service. If patient was enrolled on date of service but lapsed subsequently, the denial is invalid. Screenshot or PDF of eligibility check is primary evidence.
02
Contact employer HR if enrollment lag is suspected
For BCBS and UHC commercial plans, enrollment lag between employer HR submission and payer system update is common — employer confirmation that enrollment was submitted prior to date of service is strong evidence.
03
Attach all enrollment proofs in a single packet
Insurance card, enrollment confirmation, eligibility verification screenshot, and employer letter if applicable. Payer reviewers need all evidence in one submission — incomplete packets increase rejection risk.
04
Request retroactive reinstatement if enrollment lapsed
If patient's enrollment was retroactively reinstated by employer or payer, attach reinstatement notice. Retroactive reinstatement fully resolves enrollment denials in most cases.
Applicable payers
COV-001
Coverage Gap
Denial based on claimed plan exclusion, benefit limit, or non-covered service
62.5%
Corpus Overturn Rate
N=16
Precedents
When to use
Denial reason: "service not covered," "benefit exhausted," "plan exclusion," or "non-covered benefit." MHPAEA parity is the primary lever for behavioral health coverage gap denials — verify whether a comparable medical/surgical service would be covered before drafting the appeal.
Required documentation
Patient's plan Summary of Benefits (SBC)
Policy language (applicable section)
MHPAEA parity comparison (if applicable)
Clinical documentation supporting covered service
State parity law citation (if state-specific)
Appeal steps
01
Verify policy terms — is this actually excluded?
Pull the patient's SBC and plan document. Many coverage gap denials misapply policy language. Confirm whether the denial is based on an actual exclusion or an erroneous interpretation. If the service is covered, cite the policy section directly.
02
Evaluate MHPAEA parity applicability
For BH coverage denials: identify whether a comparable medical/surgical condition would receive coverage. If yes, cite MHPAEA — payers cannot apply more restrictive coverage limits to mental health/SUD than medical/surgical. This overturns coverage exclusions in a substantial portion of corpus cases.
03
Cite state parity law if applicable
Many states have parity laws that exceed federal MHPAEA standards. Washington (WA SB 5432), California, and New York have particularly strong state parity requirements. Reference applicable state law if the patient's plan is state-regulated.
04
Attach clinical documentation
Even coverage gap appeals benefit from clinical documentation — it removes payer arguments that the service was not medically necessary, isolating the dispute to the coverage question alone.
Applicable payers
DOC-001
Documentation Gap
Denial based on insufficient clinical documentation, missing records, or inadequate notes
53.8%
Corpus Overturn Rate
N=13
Precedents
When to use
Denial reason: "insufficient documentation," "records not received," "notes do not support medical necessity," or "LOCUS/clinical criteria not met." Do not file this appeal until documentation is genuinely complete — documentation gap appeals filed with still-incomplete records have low success probability across all payers.
Required documentation
LOCUS score (behavioral health)
GAF score
Full clinical record / progress notes
Treatment plan (signed by clinician)
Clinician attestation letter
Diagnosis codes with DSM-5 mapping
Functional impairment documentation
Appeal steps
01
Obtain complete clinical records first
Do not draft the appeal until LOCUS scores, GAF, and full progress notes are in hand. Missing documentation at appeal stage is the primary cause of failed documentation gap appeals. Obtain a signed clinician attestation confirming completeness of records.
02
Map clinical findings to payer criteria
Most payers use InterQual or Milliman criteria for BH medical necessity. Map the clinical record explicitly to criteria — "Patient meets InterQual criterion X.Y: [quote]." Don't assume reviewers will draw connections; make them explicit.
03
Include LOCUS/GAF scores in appeal letter
Summarize LOCUS and GAF scores in the appeal letter body (don't just attach the form). A LOCUS score of 24+ typically supports inpatient; 18-23 supports intensive outpatient. Reference the score explicitly against the level of care being appealed.
04
Document functional impairment
Payer reviewers look for documented functional impairment — inability to work, care for self, maintain relationships. Include specific examples from progress notes (e.g., "patient missed 8 of 10 workdays in the prior month due to symptom severity").
05
Request peer-to-peer review if available
For Optum and Anthem documentation gap denials specifically, request a peer-to-peer clinical review between the treating clinician and the payer's medical reviewer. This converts a paper appeal to a conversation, which frequently overturns documentation-based denials.
Applicable payers