Oncology denials &
prior authorization support

Complex oncology claims need more than follow-up.

Q: What types of claims do you review?

We focus on oncology reimbursement issues such as infusion and drug claims, medical necessity denials, prior authorization-related rejections, and documentation gaps around radiation and biomarker testing.

Q: How long does the appeals process take?

Appeal deadlines and response times vary by payer and denial type. For Medicare Part B, first-level redetermination requests generally must be filed within 120 days. For prior authorization, CMS benchmarks for impacted payers include 72 hours for expedited requests and 7 calendar days for standard requests. We set payer-specific expectations upfront.

Q: What is your pricing model for clinics?

Clinic recovery projects may be structured on a contingency basis: a percentage of recovered dollars. Prior authorization support, documentation review, and ongoing payer follow-up are scoped before any engagement begins.

Q: Do you handle prior authorizations, or just denials?

Both. Prior authorization is often where denials start, so we address it upstream as part of the same engagement with PA submissions, follow-ups, expedited review requests, corrected claim review, and PA denial appeals when appropriate.

Denials rarely turn on follow-up alone — they turn on medical necessity, authorization history, and the clinical record behind the claim.

How a denied claim moves once it reaches usOpen claim path

Issue under review

CO-50 denial
Missing authorization
Coding / documentation gap

Claim path identified

Corrected claim
PA or payer follow-up
Appeal support

Supporting record matched

Claim detail
Chart support
Payer criteria

Follow-up record

Deadline logged
Payer response
Next action

120 days

Medicare redetermination filing window¹

13 hrs

Weekly PA admin time²

72 hrs / 7 days

Expedited / standard PA decisions³

¹ CMS Medicare FFS appeals · ² AMA Prior Authorization Physician Survey · ³ CMS prior authorization final rule

Where We Support Oncology Billing Teams

We add senior capacity on the hardest denials and authorizations — so your team can keep daily billing and patient care moving.

Denial Triage & Recovery

We review denied infusion administration, drug, and biomarker-related claims, then identify whether the right path is correction, resubmission, payer follow-up, or appeal.

Infusion drug denials (J-codes)
Corrected claim review
Medical necessity appeals
Timely filing appeals

Prior Authorization Management

Support complex prior authorizations for biologics, high-cost infusions, and supportive care with clear follow-through and peer-to-peer preparation when needed.

Biologic & biosimilar PAs
Infusion center protocols
Expedited review requests
PA denial appeals

Coding & Documentation

Review CPT/HCPCS coding for infusion administration, address ICD-10 medical necessity gaps, and strengthen claims with the clinical evidence payers require.

Radiation coding context
Infusion administration coding
Medical necessity letters
LCD and biomarker documentation

Peer-to-Peer Support

Prepare peer-to-peer packets and help coordinate payer medical director calls when physician review is needed, including scheduling support, preparation, and next-step documentation.

Medical director coordination
Evidence packet preparation
Appeal letter follow-up
Decision tracking

See the full engagement model

Care context

The denial code is not the whole account.

Behind an infusion claim is a course of care, an authorization history, and a documented clinical rationale. Those records have to be read together before the next action is selected.

Payer responseAuthorization recordTreatment recordAppeal window

How We Review a Denied Oncology Claim

A walk-through of one denied claim — from the payer's remittance to a payer-ready appeal.

Illustrative denied-claim reviewDenial EOB · supporting record · next-action routeOpen example

Denied Claim

PatientX847 (de-identified)

CodesCPT 96413 + 96415HCPCS J9312 x 70

Service DateMar 14, 2026

PayerMedicare Part B

Denial CodeCO-50 / MA-01

Illustrative amount$5,352.72

Documents

EOB — DenialPDF · 6kb

Clinical notesPDF · 22kb

Policy supportPDF · 4kb

Remittance Advice

Medicare Part B · Claim #MCR-2026-04182

Claim Summary

PatientX847 (Member ID: MCR-00847)

ProcedureInfusion therapy - Rituximab (CPT 96413 + 96415, J9312 x 70)

ProviderCoastal Oncology Group

Date of ServiceMarch 14, 2026

Illustrative Claim Amount$5,352.72

Allowed Amount$0.00

Denial Reason

CO-50MA-01

This service was denied because medical necessity has not been established for the billed procedure. The documentation submitted does not support the medical necessity of the service.

Your Appeal Rights

For Medicare Part B redeterminations, appeals generally must be filed within 120 days of receiving the initial determination. Appeals should include additional clinical documentation supporting medical necessity.

Provider appeal submissions should follow the payer's instructions and include the records needed to support the requested review.

Example data. For illustrative purposes only.

Common Oncology Claim Issues We Review

These issues don't all call for the same response. The work is deciding which path actually moves the claim.

Medical Necessity

Payer rejected the clinical rationale for treatment, often requiring clearer diagnosis, treatment intent, and supporting records.

Missing Authorization

Required authorization was missing, incomplete, or not matched to the service billed.

Coding & Documentation

CPT/HCPCS, modifier, ICD-10, or medical record support needs to be reconciled before the next action is selected.

Timely Filing

Claims or appeals submitted outside payer deadlines can permanently limit recovery options.

Administrative Follow-Up

Eligibility, coordination of benefits, payer correspondence, and incomplete information requests still need disciplined tracking.

Illustrative emphasis; denial mix varies by payer, plan, and documentation set.

CO-50

medical necessity denials need diagnosis, treatment intent, and chart support tied back to payer criteria

120

days is the Medicare Part B first-level redetermination filing window from receipt of the initial determination

Varies

commercial appeal windows and evidence requirements are payer-specific, so deadline tracking matters from day one

Before the appeal pile grows

More context on the routing decisions that sit behind denied claims and authorization follow-up.

Rail lines separating and crossing at a switching point.

Claim Routing Before Appeals

A denial queue works better when correction, follow-up, documentation, and appeal paths are separated early.

Read the field note

Common Questions

How do you fit with our billing team and systems?

We work alongside your billing team as added senior capacity — supporting your current workflow, not replacing it. If a claim process isn't fully established yet, we can help build and run it. Either way, we fit into the tools and handoffs your practice already uses.

What types of claims do you review?

How long does the appeals process take?

What is your pricing model for clinics?

Do you handle prior authorizations, or just denials?

Start With a Claim Review

An initial review can identify which denials may be recoverable and which need a different path.

Request Claim Review