The appeals your clients write off. We prepare and file them.
Apellica works behind your billing team as the appeals desk: prior-authorization and step-therapy denials, medical-necessity denials, ERISA claim-file requests and Medicare Advantage post-acute terminations. Priced per appeal, not on contingency. A business associate agreement before any record moves.
of appealed Medicare Advantage denials for skilled-nursing admission were overturned. Most were never appealed.
The pilot is five denials, at no cost, judged on the work. If the five appeals are not better than what your team would have filed, you owe nothing. If they are, we quote per-appeal pricing after the pilot.
What we take off your plate
Your team was built for clean claims and follow-up. These are the denials that need a written, cited appeal, and they are the ones that get parked when the queue is long.
Prior-authorization and step-therapy denials
Formulary exceptions, fail-first overrides and quantity-limit appeals for specialty and biologic drugs, written against the plan's own criteria and the patient's record.
Medical-necessity denials
The clinical argument, the policy citation and the record excerpts assembled into one filing, with the plan's internal and external review paths mapped for the client.
Medicare Advantage post-acute terminations
NOMNC and DENC disputes for SNF, home health and rehab clients, including the BFCC-QIO expedited request and the continued-stay record.
ERISA claim-file requests and full-and-fair-review letters
For self-funded employer plans, the request for the claim file, internal rules and reviewer identity that turns a bare denial into a documented one.
Second-level and external review
When the internal appeal fails, the state or federal external-review filing, deadline-tracked and packaged for the independent reviewer.
Deadline tracking on every file
Each appeal carries its own clock. We log it, work to it and tell you in writing if a deadline cannot be met.
Five denials. No cost. Judged on the work.
Five denials your team would otherwise write off or park. Any payer, any of the categories above. Ideally two you think are winnable and three you think are lost.
We sign a business associate agreement with your company and, where the client requires it, a records authorization. Nothing with patient information moves before that.
You send the denial letter, the relevant record and the plan documents you have. We return a filed-ready appeal for each, with the citations and the deadline noted.
Your denials lead reads the five appeals. If they are not better than what your team would have filed, you owe nothing and we part ways. If they are, we quote per-appeal pricing for a defined scope.
What we need from you
A named contact
One person on your side who can answer a question about a file within a business day.
The denial and the record
The denial letter or remittance, the clinical documentation that supports the service, and whatever plan documents you hold (SPD, formulary, policy).
The clock
The date the denial was received, so we work to the real deadline, not an assumed one.
A signed BAA
Ours or yours. We handle the minimum necessary information for the appeal and nothing else.
Our turnaround promise
This is a promise about effort and timing. It is not a promise about the outcome, which the payer decides.
- Standard appeals: a draft returned within five business days of a complete file.
- Expedited matters (NOMNC, DENC, urgent pre-service): acknowledged within one business hour during business hours, started the same day.
- Deadlines: logged on intake and worked to. If a deadline cannot be met on the record we receive, we tell you in writing before it passes.
- Questions: a named person on our side answers within one business day.
Three numbers, each with its source
We do not publish a win rate. These are the published facts an appeal can stand on today.
of appealed Medicare Advantage denials for skilled-nursing admission were overturned
Across the 19 largest MA organizations, 12% of SNF admission requests were denied in June 2024. When enrollees appealed, plans reversed 95% of those denials (97% where naviHealth issued the denial). The report also notes that most denials were never appealed.
Source: HHS Office of Inspector General, OEI-09-24-00330, June 2026
prior-authorization denial rate at the highest-denying ACA marketplace insurer
KFF's analysis of the first insurer-level prior-authorization metrics published under CMS-0057-F found average denial rates of 12% in Medicare Advantage, 14% in Medicaid managed care and 18% in ACA marketplace plans for 2025, ranging up to 17% (UnitedHealth, MA) and 25% (Centene, ACA).
Source: KFF, Prior Authorization Metrics Provide New Insights into Insurer Practices, August 2026
prior-authorization decision windows now binding on impacted payers
Since 1 January 2026, Medicare Advantage, Medicaid, CHIP and marketplace plans covered by CMS-0057-F must decide expedited requests within 72 hours and standard requests within 7 calendar days, state the specific reason for a denial, and publish their prior-authorization metrics each year (first set due 31 March 2026). Prior-authorization APIs follow by 1 January 2027. Each of these is a fact an appeal can cite.
Source: CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet
Pricing, in one paragraph
Billing companies pay Apellica per appeal, quoted after the pilot for a defined scope, or per seat for teams that want to run the platform themselves. We do not take a share of the client's recovery. That keeps the fee simple to pass through, keeps your client's money out of our incentive, and avoids the fee-splitting and anti-kickback questions that contingency arrangements raise for referral relationships. The pilot itself has no charge.
Compliance note. Apellica prepares and files appeals and supporting documentation. It does not provide legal advice and is not a law firm or a medical provider. Protected health information is handled under a business associate agreement and limited to what the appeal requires. This page is general information; engagement terms are set in writing per client.
Frequently asked questions
- What does Apellica actually do for a billing company?
- We prepare and file insurance appeals for your clients' denied claims and denied prior authorizations, working behind your team. You keep the client relationship and the billing workflow. We take the denials that need a written, cited appeal and return them filed-ready or filed, with deadlines tracked.
- How does the pilot work and what does it cost?
- You choose five denials. We sign a business associate agreement, receive the denial, record and plan documents, and return five appeals. There is no charge for the pilot. You judge the work. If you want to continue, we quote per-appeal pricing for a defined scope after the pilot.
- Is pricing contingency or a share of what is recovered?
- No. Apellica charges billing companies per appeal, or per seat for teams that want to use the platform themselves. We do not take a percentage of the client's recovery in a billing-company engagement. That keeps the arrangement simple to pass through to your clients and avoids fee-splitting questions.
- What is your win rate?
- We have not published one and we will not quote one in a sales conversation. Overturn rates depend on the payer, the denial type and the record, and a single blended number would mislead you. What we can show you is the work itself: the five pilot appeals, the citations behind them, and how we score each denial before we file. Once we have enough client-authorized outcomes to report honestly, we will publish them with their denominators.
- How is protected health information handled?
- Under a signed business associate agreement before any record moves, limited to the minimum necessary for the appeal, with access restricted to the people working the file. We do not claim a certification. We describe the process and put it in writing.
- What is the turnaround?
- This is a promise about effort and timing, not outcome. For a standard appeal we return a draft within five business days of receiving a complete file. For expedited matters such as a NOMNC or an urgent pre-service denial we acknowledge within one business hour during business hours and start the same day. If a deadline cannot be met on the record we receive, we tell you in writing before it passes.
- Is Apellica a law firm?
- No. Apellica, Inc. prepares and files insurance appeals and related requests. It is not a law firm and does not provide legal advice, and it is not a medical provider. Where a matter needs a lawyer we say so.
- Do you handle oncology?
- Not oncology drug appeals. Clients with oncology caseloads are referred elsewhere for that subset. We work the rest of the denial mix.
Published reference material you can check before you talk to us: BFCC-QIO expedited appeals, step-therapy appeals, ERISA full and fair review, and the 50-state external-review index.
Start the five-denial pilot
Tell us who you are and roughly what your clients' denial mix looks like. We reply within one business day with the BAA and a short intake sheet. No patient information in this form, please.