Insurance appeals
Insurance claim denied? VCare handles your appeal.
VCare handles appeals for commercial insurance, employer-sponsored plans, and ACA marketplace plans. VCare does not currently handle Medicare or Medicaid denials.
Most appeal services charge you per case. VCare members don't pay extra — appeal help is included in your membership at $12/month.
Membership includes appeal help from day one at $12/month. Prefer a one-time purchase? VCare Assist covers a single appeal case without a monthly plan.
How VCare handles your appeal
When a member's claim is denied, VCare takes four specific steps that most patients either don't know to take or don't have time to execute correctly.
Read the denial correctly
VCare requests the insurer's clinical criteria document — the exact standard used to deny the claim. Most patients never get this. Most appeals fail because they don't address the right standard. VCare gets it first, before writing a single word of the appeal.
Build the appeal documentation
VCare coordinates with your doctor to produce a letter of medical necessity that directly addresses the insurer's criteria — not a generic LMN, but one that satisfies each requirement on their own checklist. Supporting medical records, test results, and clinical literature are gathered as needed.
Request peer-to-peer review when applicable
For prior authorization and medical necessity denials, VCare requests a direct physician-to-physician review between your doctor and the insurer's medical reviewer. This is the single most effective step in a PA or medical necessity appeal — and it has to happen within 24–72 hours of the denial. VCare moves the same day.
File the formal appeal and escalate if needed
VCare files the internal appeal in writing by certified mail, tracks the insurer's legally required response deadline, and escalates to external review if the internal appeal fails. External review is conducted by an independent organization — their decision is legally binding on the insurer.
What that looks like in practice
Client story
James C. — Neptune City, NJ
James had an endoscopy. The bill came in at $11,000. His insurance refused to pay, issuing a retroactive prior authorization denial — claiming, after the procedure was already done, that a PA hadn't been in place.
VCare reviewed the specific terms of James's plan. The prior authorization wasn't actually required for this procedure under his coverage. The insurer's denial was procedurally incorrect.
“I had an endoscopy billed at $11,000, and my insurance refused to pay. VCare discovered no pre-authorization was actually required, filed an appeal, and my responsibility went from $11,000 down to just $250.”
James C. — Neptune City, NJ
James's responsibility: $11,000 → $250.
What types of denials VCare handles
Prior authorization denied
Your procedure was blocked before it happened, or the insurer retroactively claims a PA wasn't in place. VCare coordinates peer-to-peer review within the window and files the formal appeal.
Prior authorization denied — full guide →Not medically necessary
The insurer's utilization reviewer determined the submitted documentation doesn't meet their clinical criteria. VCare requests the clinical criteria document, coordinates a targeted letter of medical necessity, and builds the appeal against the insurer's own standard.
Not medically necessary denial — full guide →Administrative or coding denial
Missing information, wrong billing code, or out-of-network error. VCare reviews the paperwork, coordinates a corrected claim from your provider, and confirms the denial is resolved without a formal appeal where possible.
Claims and coding errors — how VCare reviews them →Coverage dispute
The insurer claims the service isn't covered under your plan. VCare reviews your plan terms and, if the service is covered, builds the appeal around your plan's own coverage language.
VCare handles commercial and employer-sponsored plans and ACA marketplace plans. If your denial is from Medicare or Medicaid, the appeals process is different and VCare is not the right resource for that situation.
Frequently asked questions
Your insurance denied a claim. VCare handles the appeal.
Included in your membership at $12/month. No per-case charge. 70% of appeals overturned.