See a denial worked, start to finish.

The remit (835) for a residential SUD stay posts through the clearinghouse. Days 15 to 21 are denied with reason code CO-50 and remark code N10: the payer's reviewer found residential care not medically necessary after day 14.

The agent classifies the denial as clinical, not billing, so a corrected claim would not help. It records the provider dispute deadline (365 days for a DMHC-regulated plan) and notes that the member's IMR route is open if the internal appeal fails. The claim moves to the top of the queue because the stay was recent and the value is high.

The agent reads the denial letter, pulls the criteria the reviewer cited, and finds chart entries that answer each point, with page numbers.

The agent drafts a letter that takes the reviewer's points one at a time, cites the page for each answer, adds a timeline of the stay, and builds an exhibit index. It also flags that the physician should write a short letter.

A specialist checks every statement against the chart. In this example they cut one sentence the chart did not support, tightened the timeline, and attached the physician's letter. Nothing goes out without this approval.

The appeal goes out through the payer's published channel. Where a payer only takes portal uploads, a credentialed person submits it. The confirmation number and delivery proof are logged against the claim.

The claim stays on a watch list until the decision posts and the payment matches the remit. If the payer overturns the denial, the payment is reconciled. If it is upheld, the case moves to the next level, and for this plan type the member can request Independent Medical Review with their signed authorization.