DRG assignment accuracy
Principal diagnosis selection, secondary diagnosis capture, and procedure coding verified against the medical record and official guidelines.
The most rigorous DRG-downgrade appeal recovery a community hospital can deploy.
ApexAppeal assembles a documentation-complete appeal packet — every clinical record pinpoint, every ICD-10 guideline citation, the payer policy crosswalk, and the timely-filing calendar — checked against official coding guidelines and payer policy before a credentialed coder or physician advisor signs release.
Every ICD-10-CM/PCS Official Guideline citedPayer clinical-validation policy crosswalkedFull medical record synthesisCredentialed coder & physician advisor sign-off5-business-day SLA
Why appeals fail
A single missing citation can forfeit the entire recovery.
A hospital's DRG-downgrade appeal is only as strong as the clinical and coding argument behind it. Miss a relevant ICD-10 guideline, fail to map a payer's clinical-validation policy, mis-time the appeal window, or omit a key record pinpoint — and the denial stands, the revenue is lost, and the write-off is permanent.
Most hospitals run appeals by hand, from memory, with a small team that can only review a fraction of denied accounts. The payer's policy has not been read end-to-end since the last denial. That is exactly where recovery gaps hide.
ApexAppeal exists to close that gap with a single, exhaustive standard applied identically to every file.
74%
overturn rate for specialist-led appeals vs. ~30% for generalist billing staff
The benchmark
Measured against the letter of the guidelines — guideline by guideline.
We do not summarize the guidelines and hope. Every appeal is scored against a versioned rule pack tied to the exact text of ICD-10-CM/PCS Official Guidelines and the payer's clinical-validation policy. These are the provisions each appeal is held to.
Procedure coding completeness
All significant procedures coded per root operation, body part, approach, device, and qualifier — no omissions or over-coding.
Medical necessity & severity of illness
Clinical criteria for diagnosis and procedure validated against payer-specific policy, with pinpoint citations to the record.
Inpatient admission criteria
Medical necessity for inpatient status supported by physician orders, nursing notes, and clinical indicators.
Reporting additional diagnoses
All coexisting conditions that affect patient care, treatment, or length of stay are captured and coded.
Appeal window compliance
Appeal filed within the payer's contractual deadline (30 days to 1 year), verified deterministically.
How an appeal is built
Intake to credentialed sign-off, with deterministic gates the AI cannot overrule.
AI extracts and drafts. Deterministic rules — running as code, outside the model — decide what is complete. A credentialed coder and, for clinical-validation denials, a physician advisor review the exception and sign. That order is never reversed.
01
Recovery Diagnostic
Upload the denial remittance and medical record. We return a free completeness read: which coding and clinical arguments are available, and which are missing.
02
Record synthesis & guideline mapping
As your authorized clerical agent, we read the full medical record, map it against ICD-10-CM/PCS Official Guidelines and payer policy, and build the evidence matrix.
03
Grounded drafting
The appeal letter is drafted from your validated data and the rule pack into field-locked templates — no legal opinions, no invented facts.
04
Deterministic completeness gates
Every guideline citation is verified; every record pinpoint is checked; the timely-filing window is confirmed; any failure blocks release.
05
Credentialed sign-off
A credentialed coder reviews the exception queue and signs. Clinical-validation denials route to a physician advisor for sign-off.
06
Delivery
You receive the appeal packet: signed letter, evidence log, payer policy crosswalk, and timely-filing calendar — ready for the hospital to file under its own name.
The bar we hold
Rigor you can measure.
100%
Credentialed sign-off
No appeal ships without a human signature.
5 days
Standard SLA
From complete intake to signed appeal packet.
<1%
Critical-defect target
Tracked against a gold-standard appeal library.
3
Review layers
AI draft, deterministic gates, credentialed human sign-off.
Why ApexAppeal
Built to be the most thorough option a hospital has.
Documentation-complete, by design
The deliverable is completeness itself — every guideline citation and record pinpoint accounted for or explicitly exception-coded. Nothing is left implicit.
Deterministic, not vibes
The gates that decide completeness are code, not a model's opinion. A drafting error cannot slip past a guideline requirement.
In its lane, on purpose
We prepare documentation and run searches as your clerical agent. We never contact the payer, give legal advice, or represent you in any appeal hearing.
Engagement
Contingency on recovered dollars. No upfront fees, ever.
Simple, predictable, and aligned with a recovery outcome — not a subscription you pay regardless of results.
- A free Recovery Diagnostic before you commit — see exactly what arguments are available.
- One contingency percentage per recovered net dollar; disclosed pass-through costs (if any).
- Optional fixed-fee physician advisor review for clinical-validation denials.
- Optional Prevention Analytics Add-on for monthly root-cause reports to reduce future denials.
FAQ
Questions, answered precisely.
Is ApexAppeal a law firm?
No. ApexAppeal, a service of Your Deputy, Obuke LLC, provides documentation-completeness services. It is not a law firm, does not provide legal advice, and does not represent you in any legal matter. Attorney review is available and recommended for complex or high-value appeals.
Do you contact the payer or represent us in hearings?
Never. ApexAppeal is not a collection agency and does not contact payers or represent you in any appeal hearing. The hospital remains the claimant and the party responsible for filing all appeals.
What makes an appeal 'complete'?
Completeness is defined by the guidelines: every relevant ICD-10-CM/PCS Official Guideline cited, payer clinical-validation policy crosswalked, record pinpoints verified, and timely-filing window confirmed. Deterministic gates enforce each one before release.
How fast is it?
The standard SLA is five business days from complete intake to a signed appeal packet. The free Recovery Diagnostic is returned much sooner and tells you exactly what arguments are available.
How are you priced?
A contingency percentage of net dollars recovered. No upfront fees, no subscription, no percentage of any amount not recovered.
See what's missing before it costs you a recovery.
Start with a free Recovery Diagnostic. Send your denial remittance and medical record and we'll return a completeness read against every relevant ICD-10 guideline and payer policy.
Documentation-completeness service · not legal advice · the hospital files every appeal.