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Solutions for organizations

A denied claim is the start of a process, not the end of one.

Every employer plan has to give people at least 180 days to appeal a denial. mediloop reads the denial, and a human advocate helps the employee or member build and file the appeal before the deadline passes.

A human advocate on every caseDirect intake for the personAggregate reporting
What it is

Denial appeal support as a benefit

Denial appeal support helps an employee or member challenge a health insurance claim the plan refused to pay. mediloop reads the denial letter and EOB to find the stated reason, and a human advocate helps the person gather what answers it and file the appeal.

The plan still decides the appeal. mediloop doesn't decide claims or act for the plan. It makes sure the person uses the process they're entitled to, on time, with the right evidence.

How appeals work

Two chances to overturn a denial, each with a deadline.

01

Read the denial

The EOB and denial letter give the reason. A coding problem, missing paperwork or a medical necessity decision each need a different answer.

Reason and deadline
02

Internal appeal

Employer plans must allow at least 180 days to appeal, reviewed by someone who wasn't the original decision maker and gives no deference to the first denial.

At least 180 days to file
03

External review

After a final denial, an independent reviewer can look at it. Requests are generally due within four months, and the plan must accept the reviewer's decision.

Generally within four months

Which external review route applies can depend on whether the plan is insured or self-funded.

How mediloop works it

AI reads the paperwork. A person builds the appeal.

01

The person sends their documents

The denial letter, EOB and bill come straight from the employee or member, who authorizes their own case. HR isn't asked to intervene with the plan.

02

AI-powered investigation

mediloop's AI reads the denial reason, the codes and the dates, and flags the deadline and what evidence the appeal will need.

03

A human advocate files it

The advocate helps the person request records, prepare the appeal and follow it through, and handles the remaining bill whatever the outcome.

Sources

Where these facts come from

  1. HealthCare.gov, Internal appeals, Centers for Medicare & Medicaid Services
  2. HealthCare.gov, External review, Centers for Medicare & Medicaid Services
  3. US Department of Labor, Filing a claim for your health benefits, US Department of Labor, Employee Benefits Security Administration
  4. eCFR, 29 CFR 2560.503-1, ERISA claims procedure, US Government Publishing Office, Electronic Code of Federal Regulations
  5. CMS, How to read an explanation of benefits, Centers for Medicare & Medicaid Services
Questions buyers ask

Denial appeals, answered.

The appeal process is something the plan already has to offer under ERISA. Helping employees use it properly, with the right documents and on time, means fewer half finished appeals and fewer employees asking HR to step in. The plan, through its claims administrator, still decides.
Employer group health plans must give at least 180 days after the denial to file an internal appeal. External review is generally requested within four months of a final denial. The denial notice states the deadlines that apply.
No. Outcomes depend on the denial reason and the evidence. What mediloop makes sure of is that the appeal is filed on time, answers the stated reason and is followed up.
Agreed aggregate reporting only. Denial letters, medical records and case details stay between the person and mediloop.

Billing errors · Hospital financial assistance · Surprise bills · Security and data · For employers

Last reviewed

Agent Loop, the mediloop fox mascot, striking a superhero pose

Help people answer a denial before the deadline passes.

Tell us about your organization and how people handle denied claims today. We'll review the fit and come back to you about a pilot.

Prefer email? sales@mediloop.ai