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Pollenix Docs

Denial appeal letter

AI-drafted denial appeal letters

Per-denial appeal letter generation. Triggered from any row in /admin/denials. Pairs with predictive scrubber (prevention) — this surface is the cleanup pass for denials that got through.

What it generates

A payer-specific appeal letter that cites:

  • The original claim id + service date + denied amount.
  • The CARC + RARC the payer returned.
  • The clinical evidence supporting medical necessity (FHIR Condition
    • Observation + MedicationRequest resource refs).
  • The applicable medical-policy clause from the payer’s published policies (where Pollen8 has the policy on file).

Drafter is advisory — a biller reviews + signs before sending.

Per-payer formatting

Different payers want appeals in different formats. The drafter selects the right template per payer:

  • BlueCross BlueShield, Aetna, Cigna, UnitedHealthcare have pre-baked letter formats.
  • Smaller payers fall back to a generic appeal template the biller can customize per payer.

Submission

Letter outputs as a downloadable PDF + structured 276/277 message where the payer accepts electronic appeals. Submitted appeals get a tracker row in /admin/denials with status (submitted → accepted / denied_again / partial_pay).

Worklist integration

/admin/denials is sorted by impact (denied $ × payer volume). Per denial, actions:

  • Appeal — kicks the drafter.
  • Write off — close out, log rationale.
  • Correct + resubmit — for cases where the original claim had a fixable error (modifier missing, wrong Dx, missing prior auth). Builds a Frequency-7 corrected claim via the standard 837 path.

Audit

Every drafted letter persists as a Communication resource with the originating Claim + Denial + the final letter PDF attached. Pre-discovery defensibility for any payer dispute.