Decide
Understand the denial, determine the appropriate next action, and decide which claims deserve recovery effort at all.
Soft Appeals · how it works
From denied claim to documented resolution.
Soft Appeals gives selected denied claims a defined recovery workflow. We start by determining what happened and what action, if any, is appropriate. Claims accepted for recovery then move through research, documentation, preparation, client approval, submission, follow-up and reconciliation. Your existing billing operation stays where it is. Soft Appeals provides focused ownership for the denied claims assigned to us.
BAA before PHI
No routine EHR access for the initial review
Client approval before submission
Payments go directly to your organization
The shape of it
Decide, recover, resolve.
Three phases, seventeen steps. The pathway is claim-specific, because not every denial becomes an appeal and the ones that do not all follow the same route.
Recover
Research the applicable pathway, organize the evidence, prepare the required action, obtain your approval, and submit.
Resolve
Track the payer response, manage the next steps, reconcile the outcome, and close the recovery record with a disposition.
Phase 01 Decide
Decide where recovery effort belongs.
Six steps, all of which happen before there is a fee attached to anything.
01
Establish the secure workflow
Before protected health information is exchanged, the applicable Business Associate Agreement and the engagement process are established. Your organization knows how information will be provided, what is being requested, who is authorized to communicate with Soft Appeals, what systems may be involved, how approval will work, and how information is handled when the engagement ends. The complimentary review does not require routine access to your EHR.
02
Provide the initial denials
Start with 20 recent denied claims, sent through the designated secure process. Useful information may include denial or remittance information, payer information, claim details, denial correspondence, submission or acknowledgement evidence, authorization information where relevant, and the documentation needed to understand the denial. You do not need to organize everything perfectly first. If something further is needed, we identify what and why.
03
Review and classify each denial
The first question is not how to appeal this. It is what the appropriate next action actually is. Each reviewed claim is assessed on the information available and placed into a recommended disposition: correct or resubmit, appeal, investigate, or close and deprioritize. Not every denied claim should consume the same amount of time.
04
Prioritize the work
Claims are not ranked by denied amount alone. Priority weighs the financial value, whether a known deadline needs attention, whether there is an identifiable next action on the information available, and whether the information needed for that action is actually to hand. Claims needing more immediate attention surface first.
05
Receive your Denial Recovery Assessment
You receive an assessment showing the reviewed claims and their recommended next actions: claim reference, payer, denied amount, denial category, recommended action, priority, known time sensitivity, information still needed, the basis for each recommendation, and who owns the next step. The assessment belongs to your organization whether or not you continue.
06
Decide what moves forward
The complimentary review does not push every assessed claim into paid recovery work. You decide. Engage Soft Appeals for eligible recovery work, route correction items back to your billing team, provide more information on the claims needing investigation, handle selected items internally, or take no further action at all. If you continue, the recovery scope is agreed before work proceeds.
Phase 02 Recover
Turn selected claims into an organized worklist.
Six more steps, for the claims you chose to move forward.
07
Confirm the recovery pathway
For each assigned claim we determine the appropriate next administrative pathway on the information available. That may be corrected-claim or resubmission guidance, a reconsideration, an internal appeal, a further internal review, external or independent review where it applies, a payer-specific administrative process, or another appropriate action within scope. There is no single appeal ladder that fits every payer, plan and denial.
08
Confirm timing requirements
The relevant timing requirement is documented, or flagged for confirmation, before the claim advances. Timing can depend on the payer, the plan, the denial type, applicable contractual terms, the governing program, the jurisdiction, the stage of review and the claim's own circumstances. Where timing cannot be confirmed from what is available, it becomes an item to resolve rather than a number to guess.
09
Build the evidence record
A persuasive letter is one part of an appeal. The supporting record is the rest. Depending on the claim, the file may hold the denial notice or remittance information, the original claim information, submission acknowledgements, payer correspondence, authorization information, relevant medical or administrative documentation, the applicable payer requirements, and any prior appeal activity. Where clinical, coding, legal or other specialized judgment is needed, the requirement goes back to the right person at your organization.
10
Prepare the appropriate action
We prepare the administrative recovery materials the selected pathway requires: identifying the disputed denial, organizing the relevant claim facts, addressing the payer's stated reason, incorporating the supporting documentation, referencing the applicable payer requirements where that helps, and assembling the submission package. Technology assists with research, organization, workflow and drafting. It does not authorize the appeal or replace review of the work.
11
Client review and approval
Before a payer submission is made in your organization's name, the agreed approval process is completed. That is your chance to verify claim-specific information, supply anything missing, catch a factual error, obtain the internal or clinical input a claim needs, and approve the submission. Nothing reaches a payer under your authority without it.
12
Submit and document
Approved materials go through the appropriate submission channel, and the record captures the submission date, the method, the acknowledgement or proof of delivery where one is available, what was submitted, the follow-up date, the payer reference information and the current status. Sending an appeal is not the end of the work. It is the next tracked event.
Phase 03 Resolve
Follow the claim through resolution.
Five steps, and this is the phase most denial work quietly skips.
13
Track the payer response
After submission we monitor the assigned workflow for the next required action: acknowledgement of receipt, a request for additional information, an appeal decision, payment activity, a continued denial, administrative follow-up, or another available review step. The point is to stop the recovery record turning into a second unowned queue the moment the first submission goes out.
14
Respond to additional-information requests
When a payer asks for more, the request is documented and assigned. If we already hold the information, the response is prepared within scope. If it has to come from your organization, the requirement goes to the right contact with the deadline attached. If it needs clinical, coding or legal judgment, it goes to a qualified party. The workflow makes the blocker visible rather than letting the claim stall in silence.
15
Evaluate the next step after another denial
A continued denial does not automatically mean appeal again. We look at what the payer decided, what pathway remains available, and whether further recovery activity is appropriate at all. The recommendation may be to provide more information, pursue another available internal review, evaluate external review where it applies, investigate a different administrative remedy, return an issue for specialized review, or close the effort. Escalation is a decision, not a sequence.
16
Reconcile recovered reimbursement
When the payer issues reimbursement, the payment continues through your organization's normal process. Soft Appeals does not receive payer reimbursement on your behalf and never takes custody of payer funds. The outcome is reconciled against the applicable remittance or payment documentation, so the recovery can be verified from your own records.
17
Close the recovery record
Every assigned claim reaches a documented disposition: recovered, corrected and returned to your team, no further Soft Appeals action, client action required, or closed. A claim should not disappear simply because activity stopped happening to it.
What you can see
The status of a claim should never be a mystery.
For every assigned claim, the workflow exists to answer six questions at any moment.
01
Where is it?
The current status.
02
Who owns the next action?
Soft Appeals, your organization, your billing partner, or another appropriate party.
03
What happens next?
The next required recovery step, named rather than implied.
04
When does it need attention?
The known deadline or the follow-up date.
05
What is blocking it?
Missing documentation, a payer response, an internal review, or another dependency.
06
What was the outcome?
Recovered, returned, closed, or another documented disposition.
Standard workflow statuses
Every assigned claim sits in exactly one of these.
The same set is used on every engagement, so "where is that claim" has one answer rather than a conversation. The two in copper are the points where the claim is with your team rather than with us.
Received
Under review
Additional information needed
Correction recommended
Appeal recommended
Client review
Approved for submission
Submitted
Payer follow-up
Additional review or escalation
Recovered
Closed
Not every claim uses every status. The status reflects what that specific claim actually requires.
Who does what
Soft Appeals adds capacity. Your existing team keeps its role.
Every action in the workflow has an owner. These are the three sets, and the exact split is agreed before recovery work begins.
Your organization
Your team may be responsible for:
- Providing the initial claim information
- Identifying authorized contacts
- Supplying requested supporting records
- Providing required clinical or coding input
- Reviewing appeal materials
- Approving submissions
- Completing actions that stay inside your billing workflow
- Providing the remittance information needed for reconciliation
Soft Appeals
Depending on scope, we may be responsible for:
- Reviewing the assigned denials
- Categorizing and prioritizing claims
- Researching recovery requirements
- Identifying missing information
- Preparing administrative appeal materials
- Organizing supporting evidence
- Maintaining the recovery worklist
- Documenting submissions
- Tracking payer responses
- Identifying the next available review pathway
- Coordinating follow-up activity
- Reconciling recovery outcomes
Your billing partner
Your existing biller keeps:
- The broader revenue cycle
- Claim submission and payment posting
- Routine corrections
- Coding decisions and coding review
- Anything a corrected claim requires
When an item belongs back inside the billing workflow, a corrected claim or a coding review for example, the requirement is identified and routed there rather than absorbed. Soft Appeals works alongside the existing operation instead of building a competing one.
What happens when
The eight situations that decide whether a process is real.
Any workflow looks good when a claim goes to plan. These are the cases where most of them quietly fail.
01
The denial only needs a corrected claim
We document the correction or resubmission recommendation and the information supporting it. The correction itself sits with your billing representative unless that activity is expressly inside the agreed scope.
02
Clinical documentation is missing
The required record is identified and requested through the established workflow. Soft Appeals does not create clinical documentation, and does not write rationale a treating provider has not documented.
03
The denial looks like a coding issue
It is flagged for review by a qualified person. Soft Appeals does not change coding outside the agreed scope, and a coding change made without qualified review is a bigger problem than the denial was.
04
The payer asks for additional information
The request becomes a tracked action item with its own deadline. We handle the administrative response within scope and name anything that has to come from your team.
05
The appeal is denied again
The remaining pathway is evaluated before another action is taken. What comes next depends on the claim, the plan, the payer, the previous decision, the review rights still available, the timing and the evidence that remains.
06
External review may be available
Eligibility and requirements are evaluated for that specific claim. External review is not assumed to be available for every denial, because it is not.
07
The claim is recovered
The payer pays your organization through the normal reimbursement process, and the outcome is reconciled using the applicable payment or remittance documentation.
08
Further recovery no longer makes sense
The claim is closed with a documented disposition, rather than worked repeatedly so that activity can be reported. Knowing when more effort is no longer appropriate is part of doing this responsibly.
What to have ready
Starting does not require a perfect denial database.
For the initial 20-denial review, gather what is reasonably available: 20 recent denied claims, the matching denial or remittance information, the payer name, the denied amount, claim reference information, denial correspondence where you have it, submission acknowledgement information where it is relevant, and any supporting records already sitting with the denial.
Do not send protected health information until the information-sharing process has been established. That step comes first, always.
If something needed for the assessment is missing, we identify it and tell you what it affects. A messy export is a normal starting point, not a reason to wait another month.
How long does it take
There is no responsible universal answer.
The complimentary assessment and the recovery of an appealed claim are two different timelines, and only one of them is ours to control. Recovery timing depends on the volume and complexity of the claims, the information available at intake, how quickly missing information arrives from your side, the payer's submission requirements, the payer's own processing and review times, whether another review level becomes appropriate, and whether more documentation is requested along the way. We track the process and its dependencies rather than promising a recovery date the payer ultimately controls.
What we do not control
A disciplined workflow cannot guarantee a payer outcome.
Soft Appeals does not control whether a payer overturns a denial, how quickly it issues a decision, whether it asks for more documentation, whether a particular appeal or external-review pathway is available at all, your clinical or coding determinations, or when payment finally arrives.
What we do control is the quality and organization of the work inside our scope: review, preparation, documentation, ownership, tracking, escalation and reconciliation. That is the part worth judging a vendor on, because it is the only part any vendor actually holds.
Process FAQ
What people ask about the workflow itself.
Q1
Does every denial become an appeal?
No. The review first determines the recommended next action. Some claims need a correction or resubmission, some warrant an appeal, some need more information, and others do not justify additional recovery effort.
Q2
Do you take over our billing?
No. Soft Appeals provides focused denied-claim recovery capacity alongside your existing billing operation.
Q3
Do you need our EHR password?
Not for the initial complimentary review. If later recovery work requires additional system access, the purpose, scope and authorization are established before any access is provided. Shared passwords should not be used for convenience, in either direction.
Q4
Who decides whether an appeal is submitted?
You do. The client-approval process is established as part of the engagement, and appeal materials are presented for your approval before anything is submitted in your organization's name.
Q5
What if our billing company wants to work directly with you?
That can be built into the engagement workflow. The goal is to give every required action a clear owner rather than to work around the team already there.
Q6
Do you guarantee recovery?
No. A recommendation to pursue a denial is not a guarantee that the payer will reverse its decision or issue reimbursement.
Q7
Do you appeal indefinitely?
No. Each new payer decision is evaluated before the next action is recommended. Claims are not escalated to manufacture activity.
Q8
How do we know what is happening with each claim?
Assigned claims are maintained with a status, a next action, an owner, the relevant timing information and a final disposition. The six questions further up this page are the ones the record is built to answer.
Q9
What happens after reimbursement?
The payer keeps paying your organization directly. The applicable remittance or payment documentation is used to reconcile the recovery outcome, so you can verify it against your own records.
Start with the decision, not the contract
See which claims deserve a recovery workflow first.
Begin with 20 recent denied claims. Soft Appeals reviews them and returns a Denial Recovery Assessment showing the recommended action, the financial value, the priority, known time sensitivity, the information still required and who owns the next step. Then you decide which eligible claims, if any, move into recovery work. The initial assessment is complimentary and belongs to your organization whether or not you continue. Questions before sending any patient information? Ask those first.