Appeal Success Likelihood Estimator
Estimates the probability that an insurance claim appeal will succeed based on denial reason, documentation strength, policy tenure, and supporting evidence.
Your estimate will appear here.
Formula
Praw = Bdenial × Fdoc × Flevel × Fphysician × Fprior × Ftenure × Fstate × Fclaim
Pfinal = Praw / (1 + Praw) (logistic compression, clamped to [0.05, 0.92])
Expected Recovery = Pfinal × Claim Amount
Where:
- Bdenial: Base success rate by denial reason (0.30–0.70), derived from AHIP and KFF appeals data.
- Fdoc: Documentation quality multiplier (0.50–1.20).
- Flevel: Appeal level multiplier; external reviews historically overturn ~40% of denials (NAIC data).
- Fphysician: Physician support multiplier (1.00–1.30).
- Fprior: Prior success history multiplier (1.00–1.10).
- Ftenure: Tenure factor = 1 + min(0.15, 0.015 × ln(1 + tenure)).
- Fstate: State external review mandate multiplier (1.00–1.08).
- Fclaim: Claim amount factor (0.90–1.05); smaller claims settle more readily.
Assumptions & References
- This tool provides an estimate only and does not constitute legal or insurance advice. Consult a licensed insurance professional or patient advocate for case-specific guidance.