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Healthcare appeals are most frequently triggered when a provider or hospital’s claim for payment is denied, not paid in full or not paid promptly by the insurance carrier. Patients can appeal when billed for services from providers or when requested medical services have been refused. Appealing improperly adjudicated healthcare claims is a legal, complex, time consuming and frustrating process, which has traditionally required extensive manual effort. The rules for appealing a denied healthcare claim varies by State and insurance product. Claims for Medicare and Medicaid are governed by federal mandate. Adding to the difficulties, each insurance carrier has its own specific procedures, format and location for appeal submission. Moreover, each State allows multiple levels of appeal in the event of an unsatisfactory result. Each escalation though, employs a different set of requirements. Different forms must be completed and the appeal sent to a different location.

The following chart is a comparison between the eAppeals electronic system and the current manual process offered by alternative manual systems.

	eAppeals	Manual Systems
Capturing data	Electronic data capture from A/R system.	Manual assembly of information.
Data conversion	Capture of key appeal data elements.	Manual search and collation of key appeal data elements.
Appeal formatting	Electronic formatting of appeals to payer specific requirements.	Random formatting of appeals.
Appeal data pool	Electronic processing of 100% of appeal data pool.	Manual processing of a small fraction of the total appeal data pool.
State and regulatory rules	Electronic application of current state specific appeal rules by line of business, if applicable.	Manual identification and arbitrary application of state specific appeal rules.
Appeal language/additional information	Capable of customizing application of contract specific requirements.	Manual application of contract specific requirements per appeal and per payer.
Payer appeal submission location	Electronic database of over 3,000 appeal units by payer class and location.	Manual identification and application (assuming location information is known).
Appeal delivery	Electronic processing.	Manual processing.
Respond to additional information request	Electronic tool for aggregation of appeal data enabling staff to maximize efficiency.	Increases outside staff without improving operational efficiency.
Tracking and monitoring	Electronic monitoring of appeals from submission through payment.	Manual system for aggregation of data and financial reporting.
Escalation	Systematic escalation of non responded or upheld appeals.	Manual identification and uncoordinated escalation of non responded or upheld appeals.