Turn denied claims into recovered revenue, at scale.
Apellica is an AI-native appeals and denial-recovery engine built for organizations that lose revenue and stall therapy starts when payers say no. We partner with manufacturers, specialty pharmacies, health systems, and infusion clinics to overturn denials faster, with documented, audit-ready evidence behind every appeal.
Revenue and access are leaking through denials
Denials are no longer an exception in the workflow. They are a structural cost.
- Across HealthCare.gov plans, roughly 19% of in-network claims were denied in 2024, yet consumers appealed fewer than 1% of those denials. (KFF, 2025)
- In Medicare Advantage, more than eight in ten appealed prior-authorization denials were overturned in 2024, yet only about 11.5% of denials were ever appealed. (KFF, 2025)
- Reworking a single denied claim can cost between $25 and $181, and many organizations never rework a large share of denials. (Experian Health, State of Claims 2025)
The gap is the opportunity. Denials that would have been overturned are abandoned because appealing them well is slow, manual, and labor-intensive. Apellica closes that gap.
Who we partner with
Pharmaceutical manufacturers
Your hub programs already cover benefits investigation and prior authorization. The appeal after a denial is where access stalls and adherence falls off. Apellica plugs in as the appeals and denial-recovery layer of your patient support program, producing payer-ready medical-necessity appeals tied to clinical evidence and plan policy. You get faster time to therapy, fewer abandoned starts, and clean reporting your access and compliance teams can stand behind.
Specialty pharmacies
High-touch therapies live or die on access. When a prior authorization is denied or a claim is rejected, every day of delay risks the fill and the patient. Apellica generates structured, evidence-backed appeals at the speed and volume your caseload demands, so your access coordinators spend less time drafting letters and more time on patients. The result is higher conversion from prescription to dispense and fewer therapies lost to administrative friction.
Health systems and medical practices
Denied claims that are never reworked are revenue you have already earned and then written off. Apellica works alongside your revenue cycle team to triage, prioritize, and draft appeals at a scale manual teams cannot reach, focused on the denials most likely to overturn. You recover more, faster, without adding headcount, and your leadership gets visibility into what was appealed, why, and with what result.
Infusion clinics
Buy-and-bill and high-cost infusion therapies carry real financial exposure when a claim is denied after the drug is administered. Apellica builds appeals that connect the clinical record to the payer's own coverage criteria, helping you protect margin on therapies you have already delivered. Apellica does not handle oncology drug appeals; clinics with oncology caseloads are referred to appropriate partners for that subset of cases.
Why Apellica
AI-native, not human-heavy. The incumbents in revenue cycle and hub services were built around large operational teams, with technology layered on later. Apellica was built the other way around. Our engine drafts the appeal, assembles the evidence, and verifies every citation, so the work scales without scaling headcount.
Proof, not promises. Our analysis of 73,987 real external-review outcomes found 46.9% of appealed denials overturned. Every appeal we produce is backed by traceable evidence and the payer's own policy language.
Institutional credibility. Apellica is headquartered at One World Trade Center in New York, and operates with the documentation, reporting, and compliance posture that procurement, legal, and access teams expect.
How it works
1. Connect and intake
We receive denials through a secure integration or structured handoff from your team, hub, or revenue cycle platform. Patient data is handled under a HIPAA business associate agreement.
2. Analyze and prioritize
Our engine reads the denial, the clinical record, and the payer's coverage policy, then scores each case on its likelihood of being overturned so effort goes where recovery is most probable.
3. Draft and verify
Apellica generates a payer-ready appeal grounded in medical necessity and the plan's own criteria. Every citation is checked before the appeal is finalized, with a human review gate available for sensitive cases.
4. File, track, and report
Appeals are dispatched through the appropriate channel, and outcomes flow back into reporting your team and ours can act on, so the program improves with every cycle.
Partnership models
Structured to fit how your organization buys and how compliance expects these programs to be governed. Specific terms are set per engagement.
Per-appeal or referral
A defined fee for each appeal produced or each case referred. Simple, transparent, and easy to budget. Well suited to providers and pharmacies that want to start with a contained scope.
Dedicated program
A managed appeals and denial-recovery program operated for your organization at scale, with service levels, reporting cadence, and integration into your existing workflow. Suited to health systems and manufacturer hub programs that need volume and consistency.
Performance-aligned
An arrangement that ties a portion of compensation to documented outcomes, structured to remain consistent with applicable compliance requirements. Because performance-based structures in healthcare carry regulatory considerations, we scope these carefully with each partner and their counsel.
A note on compliance. Manufacturer-sponsored programs must be structured with the federal Anti-Kickback Statute and Physician Payments Sunshine Act in mind. Our work is administrative and advocacy in nature: we prepare and submit appeals and supporting documentation, and we do not provide legal advice. All protected health information is handled under HIPAA and a business associate agreement. This page is general information, not legal advice; final program structures are confirmed with your compliance and legal teams.
Frequently asked questions
- How is Apellica different from a hub services vendor or an RCM company?
- Most hub and revenue cycle vendors handle the full administrative lifecycle with large human teams. Apellica is a focused, AI-native engine for the highest-leverage step: the appeal after a denial. We complement your existing hub or revenue cycle operation rather than replace it.
- Do you replace our staff?
- No. We extend your team's capacity. Apellica handles the drafting, evidence assembly, and verification at a scale manual teams cannot match, so your staff focus on the cases and patients that need a human.
- What does the 46.9% overturn figure mean?
- It comes from our analysis of 73,987 real external-review outcomes: 46.9% of appealed denials were overturned in the patient's favor. It is research-grade external-review data that we use to calibrate the engine, not a guaranteed result for any case.
- How do you handle protected health information?
- Under a HIPAA business associate agreement, with secure intake and access controls. Data is used to build and verify the appeal, and handling is scoped to that purpose.
- Can a manufacturer fund appeals support for patients on its therapy?
- Yes, when the program is structured appropriately. Manufacturer-funded access support is common, and it must be designed with Anti-Kickback Statute and Sunshine Act considerations in mind. We scope funding and fee structures with you and your compliance team.
- Do you handle oncology cases?
- Apellica does not take oncology drug appeals directly. Partners with oncology caseloads are referred to appropriate channels for that subset, while we support the remainder of the denial portfolio.
Let's recover what your organization is leaving on the table.
Bring us a sample of your denials and we will show you where the recoverable revenue and the stalled therapy starts are hiding. A partnership consultation takes about 30 minutes.