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Claim denials and appeals

Claim Denials and Appeals for Mental Health Practices

A claim denial is a payer's decision, after processing a claim, to pay less than you billed or nothing at all. An appeal is your formal request that the payer review that decision. This guide to claim denials and appeals is for psychotherapists and psychiatrists, solo or group, and for the staff who work the denials.

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4payer-type deadlines in the calculator

Sourcedeach deadline cites its federal rule

Bothpsychotherapist and psychiatrist notes

Start here

Find the deadline on the denial notice and write it down
Check it against the payer type in the calculator
Name the one issue the payer cites
Attach proof and file before the deadline

Claim denial and appeal deadline calculator

Pick the payer type, enter the date, and see the last day to file. The deadline printed on your denial notice always controls, so write that date down the day the denial arrives.

Payer type Employer group health plan (ERISA) Individual or other ACA plan Original Medicare Medicaid managed care plan

Date to count from (the date you received the notice; for Medicaid managed care, the date printed on it)

Choose a date to see the deadline.

How long do you have to appeal a denied insurance claim?

The deadline for claim denials and appeals depends on the payer type. These are the federal frameworks, and plans, contracts and states can add to them. A claim that was rejected before processing is a different problem, and it is not appealed.

Payer type	Time to file an appeal	Time for the payer to decide
Employer group health plan (ERISA)	At least 180 days after you receive the denial notice	Pre-service: 30 days with one appeal level, 15 days per level with two. Post-service: 60 days with one level, 30 days per level with two. Urgent care claims: 72 hours.
Individual and other ACA plans	180 days (6 months) after you receive the denial notice; external review request within 4 months of the final denial	Internal appeal completed within 30 days for a service not yet received, 60 days for a service already received
Original Medicare	120 days from receipt of the initial determination	The Medicare contractor generally decides within 60 days of receiving the request
Medicaid managed care plan	60 calendar days from the date on the denial notice	Standard: 30 calendar days. Expedited: 72 hours. An extension of up to 14 calendar days is allowed. Then a state fair hearing, requested within 90 to 120 calendar days of the plan's resolution notice.
Medicaid fee-for-service and Medicare Advantage	Set by the state Medicaid agency, or stated in the Medicare Advantage plan's denial notice	Set by the state or the plan; use the notice and the current manual

Sources, last checked 11/10/26: 29 CFR 2560.503-1 (ERISA group plans); HealthCare.gov internal appeals and HealthCare.gov external review (ACA plans); CMS.gov redetermination page (Original Medicare); 42 CFR 438.402 and 42 CFR 438.408 (Medicaid managed care). For Medicare Advantage see the CMS.gov managed care appeals page. Terms are in the billing terms glossary.

Reading claim denials and appeals codes: group codes, reason codes and remarks

Every denial carries a claim adjustment group code, a reason code (CARC) and often a remark code (RARC). Search the codes below, or filter by what you need to do first.

Code	What it says	Where to start
CO group code	Contractual obligation: the amount the provider cannot bill the patient under the payer contract	Read the reason code on the same line before deciding to appeal
PR group code	Patient responsibility: the amount the patient may owe	Check deductible, copay and coinsurance against the benefits you verified
CO-16	The claim or service lacks information or has submission or billing errors	Find the missing or wrong field. Correct it and resubmit if the payer allows it.
CO-29	The time limit for filing has expired	Pull your proof of timely filing and compare it with the payer's filing rule.
CO-50	Not deemed a medical necessity by the payer	Read the payer's policy. Gather the note and treatment plan. Consider an appeal.
CO-197	Precertification, authorization or notification absent	Check whether an authorization was required and on file. Ask the payer how to request review.

The full lists are on X12: group codes and CARC list. Use the payer's provider manual for what each code means for that payer.

Claim denials and appeals planning at a therapist's desk

What goes in an appeal file

Copy the denial notice and the remittance. Include the claim number, dates of service, reason and remark codes, and the appeal deadline. Note the date the notice arrived.
Name the one issue. Write what the payer says is wrong in one sentence: authorization, medical necessity, coding, enrollment, timely filing or coverage. Appeal that issue, not everything.
Attach the proof. Session note, treatment plan, authorization record, proof of timely filing, eligibility check and the corrected claim, as the issue requires. See documentation requirements.
Cite the payer's own policy. Name the policy or contract section the payer relies on, and show how the record meets it. Add the CPT guidance when coding is the issue. See the CPT and E/M code guide.
Say what you want. State the requested action, such as reverse the denial or reprocess the claim, and file before the deadline with proof of when you sent it.

Preventing claim denials before they happen

Verify benefits and eligibilityConfirm plan, coverage and the payer to bill each visit. Keep the payer contacts handy.Open the guide →Keep credentialing currentA claim billed under a provider who is not enrolled with the plan can deny on enrollment.Open the guide →Document to support the codeThe note and treatment plan have to support the service and its medical necessity.Open the guide →Code the time correctlyTime-based psychotherapy codes depend on the minutes of face-to-face time.Open the guide →Work out who pays firstWhen a patient has two plans, the order of payment decides which one you bill first.Open the guide →Compare plans by typePrivate insurance, Medicare and Medicaid follow different appeal rules.Open the guide →

Claim denials and appeals for psychotherapists vs psychiatrists

Psychotherapy denials most often come from time-based codes, authorization and medical necessity. Match the minutes in your note to the code billed, keep the treatment plan current, and check whether the plan requires an authorization for ongoing visits. See the individual psychotherapy codes guide.

Claim denials and appeals rules by payer type and state

Keep the three families of claim denials and appeals rules apart. A rule that applies to a commercial plan usually does not apply to Medicare or Medicaid, and Medicaid rules change by state. Never apply one state's deadline to another state.

Private payer rules

Employer group plans follow the federal claims procedure rule in the table above, and the plan contract can add more. Providers have separate payment dispute processes under their contracts, and those vary by plan. See private insurance billing guides and the coordination of benefits guide.

Medicare rules

Original Medicare uses the redetermination process in the table. For Medicare Advantage, use the deadline printed on the plan's denial notice.

Medicaid rules and consent

If state law permits and with the enrollee's written consent, a provider may request an appeal or file a grievance on the enrollee's behalf with a Medicaid managed care plan (42 CFR 438.402, last checked 11/10/26). Get that consent before you file. Fee-for-service Medicaid and fair hearing procedures are set by each state, so check the state Medicaid agency's current manual. For one state's detail, see MassHealth billing updates and the state billing guides.

Parity and benefit limits

The U.S. Department of Labor says most plans cannot apply visit limits to mental health benefits that are more restrictive than those for medical and surgical benefits (DOL parity page). On May 15, 2025, the federal agencies said they will not enforce the new provisions of the 2024 final parity rule while it is reconsidered, and the statute and the 2013 rule remain in effect (DOL enforcement statement, last checked 11/10/26). Raise a parity concern with the plan in writing, and ask counsel or a compliance officer when real money or legal exposure is involved.

This is operational guidance for a billing service, not legal advice.

The short version: claim denials and appeals

For claim denials and appeals, find the deadline on the notice, check it by payer type, name the one issue, attach proof and file on time. Rejected claims never enter claim denials and appeals; they are corrected and resubmitted; denied claims are corrected or appealed. Use the glossary for terms, and the MCM South guides for codes, documentation and payer contacts.

How MCM South helps with claim denials and appeals

MCM South Medical Billing Service follows up on denied and rejected claims and files appeals for psychotherapists and psychiatrists. See the mental health billing services page.

Frequently asked questions

What is the difference between a claim denial and a claim rejection?

A rejected claim was returned before the payer processed it, because of missing or invalid information, so you correct it and resubmit. A denied claim was processed and refused in whole or in part, so you correct it or appeal. A rejection was never adjudicated, so it generally has no appeal rights.

How long do I have to appeal a denied claim?

It depends on the payer type. Employer group health plans must allow at least 180 days after you receive the denial notice, ACA plans use 180 days for an internal appeal, Original Medicare allows 120 days for a redetermination, and Medicaid managed care allows 60 calendar days. Use the deadline printed on your denial notice.

Can a provider appeal on behalf of a Medicaid managed care enrollee?

A provider may file an appeal or grievance on an enrollee's behalf with the enrollee's written consent. Providers cannot request continuation of benefits that way. Get the consent before you file.

What does CARC CO-50 mean?

CO-50 means the payer did not deem the service medically necessary. Read the payer's policy, collect the session note and treatment plan, and decide whether to appeal. Medical judgment belongs to the treating clinician.

What can I do after an internal appeal is upheld?

Check the denial notice. Depending on the payer, you may have a second internal level, external review by an independent reviewer, a state fair hearing for Medicaid, or the next Medicare level. Each step has its own deadline, so log it as soon as you get the decision.

Where MCM South works

MCM South serves psychotherapists and psychiatrists in ten currently served states: GA, MA, CT, TX, FL, NY, CO, TN, NC and IL. Find payer contacts in the insurance companies contact directory.

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