Denial Appeal Workflow
SourcedMD's denial appeal pipeline. Analyze denial letters, find regulatory violations, and generate fully cited appeal letters backed by the insurer's own policies.
How it works
Upload the denial letter
Paste or upload the denial letter text. The system extracts patient info, claim details, CPT codes, and the stated reason for denial.
Automated analysis
ClarityCore cross-references the denial against the insurer's own medical policies, state and federal regulations, CMS guidelines, and clinical evidence databases.
Violation identification
The system identifies specific contradictions, regulatory violations, and procedural errors in the denial. Each finding is cited to its exact source.
Appeal generation
A fully cited appeal letter is generated with proper legal formatting, regulatory references, and the insurer's own policy language used against them.
Review and submit
Review the generated appeal, make any edits, and submit. The system tracks appeal status and can generate follow-up correspondence.
Example: Analyze a denial
{
"tool": "denial_appeal_analyze",
"arguments": {
"denial_letter": "Patient: Jane Doe, DOB: 03/15/1978\nClaim #: MC-2026-44891\nDenied: Lumbar MRI (CPT 72148)\nReason: Not medically necessary per plan guidelines.\nReview physician: Dr. Smith, MD",
"include_regulations": true
}
}Response
{
"status": "success",
"result": {
"denial_type": "medical_necessity",
"cpt_code": "72148",
"violations_found": [
{
"type": "contradicts_own_policy",
"detail": "Insurer's own Medical Policy MP-2024-SPINE-003 lists lumbar radiculopathy as meeting medical necessity criteria for MRI",
"source": "UnitedHealthcare Medical Policy MP-2024-SPINE-003, Section 4.2",
"confidence": 0.96
},
{
"type": "regulatory_violation",
"detail": "State regulation requires MRI coverage when conservative treatment has failed for 6+ weeks",
"source": "State Insurance Code §38.2-3418.1",
"confidence": 0.91
}
],
"appeal_strength": "strong",
"recommended_strategy": "Cite insurer's own medical policy contradicting their denial, combined with state regulatory requirements"
}
}Example: Generate an appeal letter
{
"tool": "denial_appeal_generate",
"arguments": {
"claim_id": "MC-2026-44891",
"denial_analysis_id": "analysis_abc123",
"format": "formal_letter",
"include_citations": true,
"urgency": "expedited"
}
}The generated appeal letter includes proper legal formatting, all identified violations with citations, the insurer's own policy language, applicable state and federal regulations, and clinical evidence supporting medical necessity.