How to appeal a New vs Established Patient denial
This denial means the payer rejected a new-patient E/M code (99202-99205) because its records show the patient was seen within the prior three years, so it considers them established, even when the three-year rule or same-specialty-same-group test actually supports the new-patient level.
Common code: CARC B16 (new patient qualifications were not met)Why payers issue it
- The payer's records show a visit within three years by the same group and specialty
- A different specialty or subspecialty in the group was treated as the same
- A prior encounter was really a different tax ID or unaffiliated provider
- The patient truly was new but the payer's history is wrong
What overturns it
- Apply the three-year rule precisely: new if not seen by the same specialty in the same group in three years
- Show the prior provider was a different specialty, subspecialty, or unrelated group
- Provide the visit history that establishes the patient was genuinely new
- Recode to the correct established level only when the patient truly was established
Worth appealing? New-vs-established denials turn on a specific, checkable rule, so they're winnable when the three-year or specialty test is on your side, and the difference between a new and established level is real dollars on every visit it touches.
Common questions
How do I appeal a New vs Established Patient denial?
This denial means the payer rejected a new-patient E/M code (99202-99205) because its records show the patient was seen within the prior three years, so it considers them established, even when the three-year rule or same-specialty-same-group test actually supports the new-patient level. To overturn it: apply the three-year rule precisely: new if not seen by the same specialty in the same group in three years; show the prior provider was a different specialty, subspecialty, or unrelated group; provide the visit history that establishes the patient was genuinely new; recode to the correct established level only when the patient truly was established. The key is matching the documentation to the payer's own rule for new vs established patient denials.
Is a New vs Established Patient denial worth appealing?
New-vs-established denials turn on a specific, checkable rule, so they're winnable when the three-year or specialty test is on your side, and the difference between a new and established level is real dollars on every visit it touches. A no-risk recovery service makes it easy to find out, you only pay on what's actually recovered, so there's no cost to working the ones that are winnable.
How does Volari handle New vs Established Patient denials?
Volari's AI agents identify new vs established patient denials in your written-off pile, build each appeal with the right documentation and payer-specific argument, file it, and follow it to payment. You pay 25% only on what's recovered, and nothing if nothing comes back.
Volari's AI agentic crew that works your pile
The same AI agents that build and file your new vs established patient appeals inside the app, each a specialist at one part of the fight, paid only on what they bring back.
See how many New vs Established Patient denials you wrote off.
A free assessment shows your real recoverable number. No risk, paid only on what we recover.