Overturn a denied MRI claim

You manage billing at Riverside Community Clinic, and Summit Health Plan has denied a patient's lumbar spine MRI. Your task is to investigate why it was denied, build a strong appeal, and work toward getting the decision overturned, helping the clinic secure reimbursement and the patient get the care they need.

Everything you need is in the appeal folder: the denial letter, Summit's coverage policy, the patient's chart notes, a supporting clinical guideline, and the clinic's letterhead. Working entirely in Claude Cowork, you'll pin down exactly why the claim was denied, line up the evidence that answers Summit's own criteria, and produce three documents the clinic can send to appeal the decision.

Click here to see the project resources

• denial-letter.md: Summit's denial, with the exact reason and the policy it cites
• MP-2043.md: Summit's coverage policy, listing the criteria a case must meet
• patient-notes.md: the clinic's chart notes for the patient
• clinical-guideline.md: the specialty-society guideline that supports the MRI
• clinic-letterhead.md: the clinic's name, address, and brand colors for the printable packet

All files are in the appeal folder inside Resources (Desktop/Resources/appeal).

Click here to see the project outputs

• evidence-summary.docx: an internal checklist that maps each of Summit's criteria to the exact evidence that proves it, easy to review and attach
• appeal-letter.docx: a formal appeal to Summit that answers the denial point by point, ready for the clinician to sign
• appeal-packet.docx: a formatted one-page packet on the clinic's letterhead, the appeal plus a short criteria-and-evidence table, ready to print or fax to Summit's appeals department