Appeal a Denial and Track It to Resolution

This guide walks through one complete appeal — from a claim denied in full to roughly $30,000 refunded — using Claude as a persistent agent that reads your documents, finds the leverage, drafts the paperwork, and keeps watch on both the insurer's portal and the provider's billing portal until the money actually moves.

It is written so you can follow the same process for your own situation. The numbers below are real.

The case in one line: An $81,477 claim was denied in full. After the appeal, it was reprocessed in-network, the patient's true liability landed at $1,898.19 against a $2,500 out-of-pocket max, and a refund of roughly $30,079 went into the mail.

Claude is a tool, not a lawyer or a doctor. It can be wrong, so you verify what matters — the deadline, the dollar amounts, the final decision. What changes isn't that the agent is always right. It's that you're no longer doing this alone and empty-handed.

Before you start: what you'll need

Gather what you can. You don't need all of it to begin — you can add documents as you go.

Your insurance card (photo or PDF)
Your Summary of Benefits and Coverage (SBC) and full plan documents if you have them (downloadable from your insurer's member portal)
The Explanation of Benefits (EOB) for the claim in question
The denial letter, if you received one
Any bills from the provider
Login access to your insurer's member portal and your provider's billing portal (for example, MyChart or the hospital's billing site)
A Claude Pro subscription (for Projects and Cowork — the persistent memory and browser-driving features this process relies on)

Step 1 — Set up your agent

The goal is to give Claude persistent memory of your whole situation, so it can reason across all of your documents at once instead of one question at a time.

Go to claude.ai and create a new Project. Name it something like "My Healthcare" or "Surgery Appeal."
Open the Project Instructions field.
Go to yourhealthcareagent.org, copy the full instruction block (the CLAUDE.md), and paste it into your Project Instructions. Save.

This tells Claude how to behave as a healthcare agent — how to ask the right questions, what rights you have depending on your plan type, how to read each document, and what your next moves are. You don't need to understand all of it. The agent does.

When you send your first message, it should greet you and ask what's going on. You can't ask it a wrong question.

Step 2 — Brief your agent

Upload your documents into the Project so they persist across every conversation:

Insurance card → establishes your plan type, insurer, group number
SBC / plan documents → the rulebook the agent will cross-reference
EOB(s) → what the insurer says happened and what they say you owe
Denial letter → the reason code, the deadline, your appeal rights
Bills → what the provider is actually asking you to pay

Then tell the agent your situation in plain language. A real example:

"I just loaded my insurance documents. I'm on a [plan type] plan in [state]. I had [procedure] at [facility]. The total claim was about $81,000 and it was denied in full as out-of-network, even though I believe it should have been in-network because of a prior authorization. I have the EOB and the denial letter. Where do we start?"

Notice what a well-briefed agent does here: it doesn't just answer. It asks the questions that determine which rules apply to you — your state, your plan type, whether your plan is ERISA-governed (a self-funded employer plan, which limits state-law protections) or fully-insured (where state insurance law applies). Those answers shape your entire appeal strategy.

Step 3 — Find the leverage

This is where an agent earns its keep. Ask it to reconcile everything you've loaded:

"Read across all of these documents. Tell me in plain English: what was billed, what the insurer paid, what they say I owe, and whether that number is actually correct. Look for anything that contradicts the denial."

In the real case, this is the step that cracked it. Cross-referencing the documents surfaced an approved prior authorization sitting in the insurer's own system that directly contradicted the denial. The patient hadn't found it. The agent found it by reading the insurer's own records against the denial letter.

Then have the agent do the math the insurer isn't volunteering:

"Based on my plan's out-of-pocket maximum and what I've already paid, what should my actual responsibility be if this is reprocessed in-network?"

In the real case, the answer was about $1,898.19 — against a $2,500 out-of-pocket max — not the much larger balance the denial implied. Knowing your true number before you call is what lets you hold a line in the conversation.

Step 4 — Know your deadline and your rights

Ask:

"What are my appeal rights here, what type of appeal applies, and what is my deadline? Are there any state laws — like prompt-pay rules — that put a clock on the insurer?"

The agent should identify:

Internal appeal rights (the first formal step with your insurer)
External review rights (an independent reviewer, available after internal appeal for most non-ERISA plans)
Expedited appeal rights if the situation is urgent
The deadline — appeals have hard windows; missing one can forfeit your rights
Any state prompt-pay statute that requires the insurer to act within a set number of days (for example, a 30-day clock)

Write the deadline down. Work backward from it.

Step 5 — Draft the appeal

Have the agent draft the formal appeal:

"Draft my internal appeal. Cite the approved prior authorization, the relevant plan language, and the deadline by which I expect a written response under state law."

A strong appeal contains:

The specific claim and service being appealed
The denial reason and exactly why it is incorrect
The contradicting evidence (here, the prior auth approval already in their system)
The relevant plan language that supports coverage
The legal or regulatory basis, including any prompt-pay clock
A clear request for the specific remedy — reprocess in-network — and a written response within the required timeline

Review it. Verify the facts and the numbers. Then file it through your insurer's official appeal channel (member portal, fax, or certified mail — keep proof of the date).

Step 6 — Protect yourself from collections while it's pending

An appeal takes time, and an unpaid balance can drift toward collections in the meantime. Have the agent draft a message to the provider's billing department:

"Draft a message to the hospital billing office letting them know this claim is under formal appeal with my insurer, requesting that my account be held from collections while the appeal is pending, and asking them to confirm the refund process and amount once the claim is reprocessed."

Send it through the provider's billing portal or patient-relations channel. This does two things: it pauses collections pressure, and it pins the provider to a refund commitment in writing.

Step 7 — Bird-dog it across both portals

This is the part almost nobody has the stamina for — and it's where a persistent agent changes the game. The insurer and the provider each see only their half of the transaction. You are the only party who can see both ends. So you watch both.

Ask the agent to set a standing routine:

"Set yourself a reminder to check both my insurer's portal and the hospital's billing portal every couple of days. Each time, pull the current claim status, note any change, update a running tracker, and tell me if anything needs my attention."

With Cowork, Claude can log into the portals, read the live claim status, and keep a running ledger. What you're watching for, in order:

The appeal is received and under review (insurer side)
The claim is reprocessed in-network — the denial reverses
Your liability is restated at the correct lower amount
The provider's billing portal reflects the new balance and the resulting credit/refund
The refund is issued — and how (wire vs. mailed check)
The refund actually clears

A running tracker for this case looked like this:

Date	Source	Status	Note
—	Insurer	Denied in full	$81,477 claim, out-of-network
—	Agent review	Leverage found	Approved prior auth in insurer's own system
—	Insurer	Appeal filed	Cited prior auth + prompt-pay clock
—	Provider	Collections hold	Refund process confirmed in writing
—	Insurer	Reprocessed in-network	Liability restated to $1,898.19 / $2,500 max
—	Provider	Refund in motion	~$30,079 — mailed check, not wire
—	Both	Pro-fee claims finalizing at $0	Anesthesia already $0; two remaining expected to match

Step 8 — Confirm the money and close the loop

When the refund issues, verify it precisely. Have the agent do the arithmetic:

"Confirm the refund amount. My prepayment was $31,977.41 and my correct share is $1,898.19 — so the refund should be $30,079.22. Flag it if what arrives is materially different."

A few real-world details worth anticipating:

Refunds often come as a mailed check, even when you paid by card or wire — providers tend to default to their standard method. Build in mail transit time.
Confirm the exact amount when it lands. If it's off by more than rounding, that's the one thing to flag and follow up on.
Watch the last small claims finalize. In this case, two professional-fee claims were still settling at $0; the agent flagged the next billing cycle as the confirmation point.

Once the refund clears and the residual claims finalize, the fight is over. Keep the paper trail — the appeal, the EOBs, the portal screenshots, the tracker — so you can defend the outcome if anything regresses later.

What actually happened here

Strip away the steps and look at the shape of it:

An $81,477 claim, denied in full, became a claim fully resolved in-network, with the patient's liability landing at $1,898.19 against a $2,500 maximum, and roughly $30,000 refunded.

The difference between that outcome and walking away wasn't expertise the patient was born with. It was the willingness to presume their own agency — and an agent with the stamina to read every document, find the contradiction, draft the paperwork, and watch both portals until the money moved.

Historically, the people who won these fights were the ones who happened to have a lawyer, a doctor, or a billing expert in the family. Most people don't. This is what it looks like when everyone does.

The reusable prompts

Copy these into your own Project as starting points:

Reconcile everything: "Read across all of these documents. Tell me what was billed, what was paid, what they say I owe, and whether that number is correct. Look for anything that contradicts the denial."
Find my true number: "Based on my out-of-pocket max and what I've paid, what should my actual responsibility be if this is reprocessed correctly?"
Rights and deadline: "What are my appeal rights, what type applies, what's my deadline, and is there a state prompt-pay clock?"
Draft the appeal: "Draft my internal appeal citing [the contradicting evidence], the relevant plan language, and the response deadline required by law."
Protect from collections: "Draft a message to the provider's billing office noting this is under formal appeal, requesting a collections hold, and pinning down the refund process."
Bird-dog it: "Check both portals every couple of days, pull claim status, update the tracker, and tell me if anything needs my attention."
Confirm the refund: "Confirm the refund amount. My prepayment was [X] and my correct share is [Y], so the refund should be [Z]. Flag anything materially different."

Part of the Your Healthcare Agent series. Billing is where the pain is loudest — but the goal is bigger: using AI as your agent across your entire experience as a patient. More guides at yourhealthcareagent.org.

This guide describes one person's experience and is for general educational purposes. It is not legal, financial, or medical advice. Your plan, your state, and your situation differ — always verify deadlines, amounts, and decisions against your own documents and official sources.