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6.15.2026 Calculating Appeal Overturn Rates for Requests for Multiple Services If a single appeal request includes multiple services with mixed outcomes, how should the organization calculate the appeal overturn rate for UM 1, Element E, factor 2?

Appeal overturn rates are calculated at the request level, not at the service or code level. An appeal request is counted once in the denominator, regardless of how many services it includes. If any part of the appeal is overturned, it counts as 1 overturned appeal decision. Therefore, a partially overturned appeal (mixed outcome) is included in the overturn rate. The number of services included in the appeal does not change the fact that it is a single request and should not be split into multiple decisions.

For example, if one appeal request includes three CPT codes and two are overturned while one is upheld, the organization counts:

  • 1 appeal request (count once in the denominator),
  • 1 overturned appeal decision (count in the numerator), and

The number of services included in the appeal does not change the fact that it is a single request and should not be split into multiple decisions.

As another example, suppose an organization processes 100 appeal requests:

  • 20 are fully overturned, and
  • 10 are partially overturned.
the appeal overturn rate would be calculated as follows: ((20 + 10) / 100) x 100 = 30%.
 
Applicable standards:
  • Health Plan Accreditation – UM 1, Element E
  • Behavioral Health Accreditation – UM 1, Element C
  • Utilization Management Accreditation – UM 3, Element E

This applies to the following Programs and Years:
HP 2026|UM 2026|BHA 2026