Most practices know their denial rate. Few can say how often an appeal wins, and fewer can split that number by payer, by reason code and by appeal level. Without the split, appeal time flows to the denials that feel productive, usually the ones with an obvious paperwork problem, while the categories that pay on appeal sit in a worklist nobody finishes.
What this covers
- Overturn rate is appeals overturned divided by appeals decided, at one level for one payer. Pending appeals and dismissals stay out of it.
- Six fields per appeal rank payers: payer and plan, CARC and RARC, appeal level, dates, outcome, dollars.
- Rank work by dollars recovered per appeal filed. A 35 percent rate on a $420 claim can beat a 65 percent rate on a $180 claim.
- Medicare Advantage plans, Medicaid managed care plans and Marketplace issuers must post their own prior authorization overturn figures each year.
A denial rate measures the payer’s behavior. An overturn rate measures yours.Both belong on the same page of the monthly report.
What an Overturn Rate Measures
An appeal overturn rate is appeals overturned divided by appeals decided, for one payer at one appeal level. Count decisions, not filings: a request still in flight is neither a win nor a loss. Fix the level you measure, because the payer reviews a first-level appeal and an independent entity reviews the second.
Leave dismissals and withdrawals out of the denominator. Plans and Medicare contractors dismiss appeals filed late or without a valid appointment of representative (42 CFR 422.582(f) lists the Medicare Advantage grounds), and a dismissal is not a loss on the merits.
| Metric | Numerator | Denominator | Question it answers |
|---|---|---|---|
| Denial rate | Claims denied | Claims submitted | How often the payer says no |
| Appeal rate | Appeals filed | Denials received | How often you push back |
| Overturn rate | Appeals overturned | Appeals decided | How often the payer was wrong |
| Recovery per appeal | Dollars paid | Appeals filed | What appeal work returns |
An overturn rate without an appeal rate hides the larger loss. Medicare Advantage plans denied 4.1 million prior authorization requests in 2024, 11.5 percent were appealed, and 80.7 percent of the appeals filed were overturned. A practice that appeals two thirds of its denials and wins half recovers more than one that wins 80 percent of the few it files, which is what denial management measures.
The Small Dataset: Six Fields per Appeal
Two documents carry what you need: the 835 electronic remittance advice and the payer’s decision letter. Pull six fields per appeal into one sheet and update it the day the decision lands.
Legal payer plus product line: a Medicare Advantage contract or a commercial PPO.
The CARC and RARC as printed, with your category label beside them.
First-level appeal, second-level review or state fair hearing.
Notice date, filing date, decision date.
Overturned, partially overturned, upheld, dismissed or withdrawn.
Billed, allowed, paid after appeal, still in dispute.
The reason code picks the fix. CARC 16 means the claim lacked information or carried a submission error, a corrected claim rather than an argument. CARC 50 means the payer does not consider the service medically necessary, a clinical appeal. CARC 197 means authorization was absent and 198 means it was exceeded, and both are re-authorization problems wearing a denial code.
Apply the same labels the same way every month. If authorization and medical necessity blur in the log, the rankings cannot tell you whether to fix scheduling or documentation.
What a Healthy Overturn Rate Looks Like
There is no single benchmark, because published rates track different decisions. A prior authorization appeal is decided against a written coverage policy. A post-service appeal asks a payer to reverse its own adjudication, and payers defend those harder.
| Appeals measured | Overturned | Period | What sits underneath |
|---|---|---|---|
| Medicare Advantage prior authorization | 80.7% | 2024 | 11.5 percent of denials appealed |
| Medicaid managed care prior authorization | About 47% | 2025 | Payer-published metrics |
| Marketplace prior authorization | About 43% | 2025 | Same federal template |
| Marketplace post-service claims | About 34% | 2024 | Insurers upheld 66 percent |
| Medicare Part B redeterminations | 51% | 2012 | Fully or partially favorable |
Oversight does not settle the rate. OIG found that the largest Medicaid plans denied one of every eight prior authorization requests in 2019, and that most states did not routinely review whether those denials were appropriate. In the states that offer independent external review, 46 percent of the appeals sent to it were overturned.
In the OIG’s review of Medicare redeterminations from 2008 through 2012, contractors decided 54 percent of appealed outpatient hospital claims favorably in 2012 against 4 percent of appealed home health claims. One payer, one year, one level, a 50 point spread. A blended practice rate moves with the denial mix.
Where to Send the Appeal Effort
Overturn rate alone ranks payers wrong, because it ignores claim size. Multiply the rate by the average allowed amount to get recovery per appeal filed, the number that sets the queue.
| Payer | Denials | Appeals filed | Overturn rate | Recovered | Per appeal filed |
|---|---|---|---|---|---|
| Medicare Advantage | 400 | 240 | 65% | $28,080 | $117 |
| Commercial | 150 | 60 | 35% | $8,820 | $147 |
The payer with the lower overturn rate pays more per appeal, so it belongs early in the queue. Lift the commercial rate to 60 percent with the treatment plan and the payer’s criteria instead of a chart summary, and the same 60 filings return $15,120, an extra $6,300. Appeal a quarter more Medicare Advantage denials at 65 percent, and 100 more appeals return about $11,700.
Set a floor first: the hours an appeal consumes against recovery per appeal filed. Below it, a denial is a write-off decision. Above it, the reason code chooses the instrument, and that ranking is the core of denial management solutions.
Reading the Payer’s Own Numbers
Since the CMS Interoperability and Prior Authorization final rule (CMS-0057-F), Medicare Advantage organizations, Medicaid managed care plans, state Medicaid and CHIP fee-for-service programs, CHIP managed care entities and Marketplace issuers must post annual prior authorization metrics by March 31, including standard requests approved after appeal. The first posting, for calendar year 2025, was due March 31, 2026.
That gives you an outside number to check against. If your rate runs far below the plan’s published figure, the appeals are the problem: thin records, the wrong level, a missed deadline. If it runs far above, the plan’s first-level review is the weak point, and unappealed denials are money left behind.
- Close the month with every appeal decided, pending, or dismissed with a reason recorded.
- Recompute overturn rate by payer and by CARC, decided appeals only.
- Rank next month’s worklist by recovery per appeal filed.
- Check the deadline calendar for anything inside 30 days.
- Send one finding back to the clinical team or the front desk, where the denial started.
Behavioral Health and ABA Denials: Where the Categories Fall
In ABA billing the authorization is the choke point. Payers authorize units per CPT code and re-authorize at intervals, so one missed re-authorization denies a batch of claims. Virginia Medicaid requires service authorization requests to list the units requested for each ABA code used, and requests at or above 20 hours, or 80 units, per week need a schedule of activities. A technician-delivered 97153 session bills in 15 minute units.
The reason codes sort those failures. CARC 198 is a units reconciliation against the authorization on file, and no clinical argument fixes it. CARC 50 is worth appealing with the treatment plan, the progress data and the payer’s coverage criteria.
Federal parity rules prohibit coverage limits that apply more restrictively to mental health and substance use disorder benefits than to medical and surgical benefits. OIG audits have found state Medicaid agencies that did not ensure their plans complied; in one audit, none of three plans completed a parity analysis, and a plan denied behavioral health prior authorizations more often than comparable medical and surgical requests.
Log denial rate and overturn rate for behavioral health services next to the same figures for medical and surgical services at the same payer. The gap is evidence if a parity question needs raising.
Appeal overturn rate questions
Divide overturned appeals by appeals decided, for one payer and one appeal level over a fixed period. Leave withdrawn, dismissed and pending appeals out of both numbers, and run the figure monthly by CARC category. A rate built on decided appeals is comparable from month to month.
There is no universal number, because published rates cover different decisions. Medicare Advantage prior authorization appeals were overturned about 80 percent of the time in 2024, Medicaid managed care prior authorization appeals closer to 47 percent, and Marketplace post-service appeals less often, with insurers upholding 66 percent.
No. A corrected claim, or reopening, fixes the record: units, dates, a missing modifier, a diagnosis pointer. An appeal argues that the payer’s decision was wrong. Keep them in separate columns and queues, because a corrected claim can be filed after the appeal window closes, and a log that mixes them hides how often your arguments land.
Rank by expected recovery: the overturn rate for that category times the average allowed amount, then apply a floor for the hours an appeal consumes. Check the deadline before anything else. A category returning $147 per appeal filed goes ahead of one returning $117, even when the second has the higher overturn rate.
It depends on the payer. Original Medicare allows 120 days from the remittance advice for a redetermination, then 180 days from that decision to the QIC. Medicare Advantage allows 60 days from the organization determination notice. Medicaid managed care allows 60 days from the adverse benefit determination notice. ERISA group health plans must allow at least 180 days.
Medicare Advantage plans, Medicaid managed care plans, state Medicaid and CHIP fee-for-service programs and Marketplace issuers must post prior authorization metrics by March 31 each year, including the percentage of standard requests approved after appeal. CMS publishes Medicare fee-for-service prior authorization statistics separately.
The bottom line
An overturn rate is only useful with its partners: the appeal rate that shows what you skipped and the recovery per appeal that shows what an hour of work returns. Six fields per appeal, decided cases only, will rank a denial inventory better than any industry average. Start with the payer that pays most per appeal filed.
How often do your appeals actually win?
Send us a quarter of appeal outcomes by payer and reason code, or a denial report from your clearinghouse. We will build the log, calculate overturn and recovery per appeal, and show you which categories are worth fighting. Our team works in ABA and behavioral health billing, and you can read how we work first.
Request a free denial auditOverturn rates, benchmarks and filing windows vary by payer, plan and state, and payer policy changes during the year. Confirm the deadline and the address printed on the denial notice before you file anything; this is billing guidance, not legal advice.
