Answers for payer-ops leaders comparing tiers.

Tier-3 denial defense covers any case where a payer has denied or downgraded a previously authorized service and your team can document medical necessity, coding accuracy, or a payer-policy mismatch. VCS RN reviewers step in at the point of denial, not at the prior-auth submission — Tier 3 starts where Tier 1 (denial intelligence and SMART compliance scoring) and Tier 2 (appeals analyst + analytics) end.

What's not covered: pure P2P work unrelated to a denial challenge, soft-claim recheck, eligibility re-verification, or new-service prior-auth submissions that haven't already hit a denial. These are outside the Tier-3 contract and would be billed separately or rolled up into your monthly reporting. The service tier itself is fully defined on /pricing — Full Denial Defense (Tier 3).

23 high-volume CPT codes today — spanning infusion, advanced imaging, pain/spine procedures, orthopedics, cardiology, and neurology — all built into our cpt_defense_library with payer-by-payer appeal templates and defender notes. We add new codes quarterly based on client denial patterns and CMS policy updates.

Specialty coverage mirrors what we walk through on the landing-page set: cardiology, infusion / oncology, multi-specialty, neurology, orthopedics, and pain management. If your top denial CPT isn't in the library yet, our clinical lead will typically audit 5–10 of your historic cases during onboarding and add it under the same Tier-3 rate — no separate scoping.

Tier-3 is priced per case, not per appeal round or per P2P attempt — and a "case" is the full lifecycle from denial receipt through Final Determination, no matter how many appeals or P2Ps that requires. Pricing is quoted by your practice size and denial volume after the working session; there is no separate fee if the case needs to escalate a second or third time.

Compare against the four-tier ladder on /pricing: Tier 1 (self-serve Playbook), Tier 2 (Playbook + Analytics with monthly SMART score), and Tier 3 (Full RN-handled Denial Defense). When an appeal doesn't overturn, you do not pay an additional escalation fee — the case closes on the original Tier-3 fee. That sentence is also on /for-tops in the Tier-1 leader pitch.

VCS's blended median turnaround across active Tier-3 clients is 72 hours from denial receipt to appeal submission — the same figure cited on /for-tops and the gold-standard turnaround for short-cycle denials. Payer-specific windows vary: most standard appeal windows are 5–14 days from denial date, and P2P scheduling windows typically run 1–5 business days depending on the payer's medical-director availability.

Tier 3 doesn't artificially shorten these windows. We hit the floor of the payer's contract, batch the appeal packet under RN review, and run morning P2P slots across Aetna, BCBS, Cigna, Humana, UHC, and Medicare — the six payers the pa_submissions SLA engine tracks. Concurrent denials are tracked on a daily digest so an executive scoring report ships every weekday morning.

Yes — a HIPAA Business Associate Agreement is required before any Tier-3 engagement goes live. The BAA covers VCS as a Business Associate and binds our staff (16 demo employees across 8 active roles, with PQ-1 background checks and role-scoped database access) to the same handling rules your in-house team follows.

Operationally, PHI stays in Knack — your existing payer-portal EHR sidecar — and our reviewers never download patient identifiers into email, shared drives, or personal systems. VCS only stores case metadata in our own schema (note that clinical_documents holds metadata, not the document itself), and every access event writes to document_access_audit so audit trails are reviewable by your compliance officer on request. We do not ingest or sell PHI for model training.

An appeal that comes back denied is fully documented and escalated under the same Tier-3 fee — Tier 3 isn't a guarantee of overturn, and we don't promise one. We document the denial basis, then escalate through the payer's internal review path (medical-director review, IRO where applicable, ALJ where federal), and capture a SMART-scored review note for each step in our system.

The internal narrative a clinic decision-maker should anchor to: ~65% overturn across contested denials (cited on /for-tops and our results page) — defensible, not miraculous. The 35% that don't overturn still generate review notes, post-denial documentation gaps, and a QA review under our qa_reviews workflow, so your team gets trend visibility even on the cases that didn't win. That's the input your CFO needs to budget to the right Tier.

Multi-site rollouts run through our HCaaS scaffolding. Each site is mapped to a client_compliance_profiles row with site-level SMART scoring, per-site service-item status (in hcaas_service_tracking), and an aggregated 5-dimension SMART score across the practice group. The same structure that already serves our 5 seeded HCaaS practices.

Onboarding creates a Master Auth ID per site (VCS-YYYY-NNNNNN format, anchored in the authorization_cases table) so case IDs stay consistent across systems, and a working session sets the per-site tier mix (typically Tier 2 at HQ + Tier 3 at the high-volume sites). Shared executive reporting rolls up at the org level, with site-level drill-down. The intake path is on /intake and the provider-onboarding path on /onboarding — both publicly reachable.

It runs in five steps. Week 1 — Working session: a VCS clinical lead scopes your top denial CPTs, payer mix, and volume. Week 1 — BAA executed: the standard HIPAA BAA is signed, Master Auth IDs are assigned, and Knack connector access is keyed. Weeks 2–3 — First wave: the first 20–30 cases are routed to VCS for RN review and Tier-3 defense. Ongoing — weekly QA: every Friday, your case load is reviewed under our qa_reviews schema, with SMART scoring per case.

Ongoing — monthly executive reporting: a Tier-3 dashboard with overturn rate, denial-rate trend, and per-payer detail ships to your leadership team. Daily — exec digest: the daily digest cron (docs/cron/daily-digest.md, also called out at the top of our CLAUDE.md) ensures the operations picture is reviewed every weekday morning by our principal team. By the second week, your team should see time-back on the prior-auth queue and the first preserved reimbursements hit.