Denial management
Denial management services
Denial management is the work of finding out why a claim was denied, fixing it, getting it paid and stopping the same denial from coming back. We correct, resubmit or appeal every denial within 5 business days, and we track root causes so your denial rate goes down over time.
- Every denial worked within 5 business days
- Root-cause tracking by payer, code and provider
- Written appeals with the records payers ask for
Root causes
Most denials come from a few fixable causes
Most denials trace back to a short list of problems that start before the claim is sent. Fixing the cause is worth more than winning one appeal.
Eligibility and coverage
The patient’s plan was inactive, the payer on file was wrong, or the service is not a covered benefit. We check eligibility and benefits before visits to stop these at the front desk.
Missing or wrong information
A missing NPI, a wrong date of birth, an invalid diagnosis code or a mismatched subscriber ID. These are usually quick to correct and resubmit.
Authorization
The service needed a prior authorization or referral that was not on file. We track which payers and services need one so it is in place before the visit.
Coding and modifiers
A code that does not match the documentation, a missing or wrong modifier, or two services that the payer bundles together. We review codes against payer edits before submission.
Medical necessity
The payer did not see enough support for the service in the diagnosis or notes. These often need an appeal with clinical records.
Timely filing and duplicates
Claims filed after the payer’s deadline, or sent twice. We submit fast and keep proof of submission for every claim.
Denial codes
Common denial codes and how we fix them
Every denial comes with a claim adjustment reason code (CARC) that tells you why the payer did not pay. The group code in front (CO, PR, OA, PI) tells you who is responsible for the balance.
CO means contractual obligation: the balance is the provider’s responsibility and usually cannot be billed to the patient. PR means patient responsibility: the patient owes it under their plan.
| Code | What it means | Typical fix |
|---|---|---|
| CO-16 | The claim is missing information or has a billing error | Read the remark code (RARC) to find what is missing, correct the claim and resubmit |
| CO-197 | Prior authorization, precertification or notification was not on file | Find the authorization number if one exists; request a retro-authorization where the payer allows it, then appeal or resubmit |
| CO-50 | The payer decided the service was not medically necessary | Check the diagnosis codes and notes, then appeal with the clinical records that support the service |
| PR-1 | Deductible: the patient owes this amount | Not an error. Post it to the patient’s balance and send a clear statement |
| CO-45 | The charge is above the contracted or allowed amount | Usually a normal contractual write-off. We compare the allowed amount to your contract to catch underpayments |
| CO-97 | The service is bundled into another service already paid | Check bundling edits; add a valid modifier and resubmit only if the documentation supports a separate service |
| CO-4 | The modifier is missing or does not fit the procedure code | Correct the modifier (for example a telehealth modifier the payer requires) and resubmit |
| CO-29 | The filing deadline has passed | Appeal with proof of timely submission, such as a clearinghouse acceptance report; otherwise the balance is usually written off |
| CO-18 | Exact duplicate of a claim already received | Check the status of the original claim. If a change is needed, send a corrected claim instead of a new one |
Code meanings come from the standard CARC list, but how each payer applies them varies. Rules vary by payer; we check current policy before we resubmit or appeal.
Our promise
Every denial worked within 5 business days
When a denial posts, we act on it within 5 business days. That means the claim is corrected and resubmitted, or an appeal is sent, or we tell you exactly what we need from you to move it.
Speed matters because appeal and corrected-claim windows are limited, and older claims are harder to collect. Working denials quickly also means you see problems while they are still small.
Across our active clients, practices have seen an average 38% reduction in denials (company-wide average). That comes from fixing causes at the front end, not only from appeals.
Appeals
How we handle a denial, step by step
- 01
Capture and sort
We read every remittance (ERA/EOB), log each denial and sort it by payer, reason code and dollar amount.
- 02
Find the root cause
We match the reason and remark codes to the claim, the notes and the payer’s policy to see what really went wrong.
- 03
Correct or appeal
Simple errors get a corrected claim. Payer decisions we disagree with get a written appeal with the records, authorization or proof the payer needs.
- 04
Follow up until resolved
We track each resubmission and appeal with the payer until it is paid, or until every reasonable level of appeal is used.
- 05
Prevent the next one
We report denial trends by payer, code and provider, and fix the process that caused them, such as eligibility checks, authorization tracking or coding rules.
Appeal levels and deadlines differ by payer and plan type. We check each payer’s current process before filing.
Pricing
Denial management is part of our billing service
Denial work is included in full billing, which costs 2.5% of collections or a flat monthly fee. Have a backlog of old denials? Start with a free 90-day claims audit.
Common questions
What is denial management in medical billing?
It is the process of finding out why claims were denied, correcting or appealing them, and fixing the causes so they stop happening. Good denial management recovers money now and lowers the denial rate over time.
How fast do you work a denial?
Within 5 business days of the denial posting. In that time we correct and resubmit the claim, send an appeal, or tell you exactly what we need from you.
What is the difference between a rejection and a denial?
A rejection is stopped before the payer processes it, usually by the clearinghouse or payer front-end edits, and can be fixed and resent. A denial was processed and not paid, so it needs a corrected claim or an appeal.
Can you work old denials from before we started?
Yes, as long as the payer’s deadlines have not passed. We start with a free 90-day claims audit that shows which older claims may still be recoverable and roughly how much they are worth.
Do you write the appeal letters?
Yes. We write and send appeals with the supporting records. If an appeal needs something only your clinicians can provide, such as an addendum or a letter of medical necessity, we tell you exactly what is needed.
Will you tell us why claims keep getting denied?
Yes. You get regular reporting on denials by payer, reason code and provider, plus the fixes we made. Many repeat denials come from front-end steps like eligibility checks and authorizations.
Guides from our team
Learn more before you decide
Top 10 Reasons for Medical Claim Denials (And How to Fix Them Fast)
The 10 most common reasons for medical claim denials, what each one costs your practice, and the exact fix for each. Plus a denial-prevention checklist.
Read the guide →Claim Denial Codes Explained: What CO-16, CO-50, CO-197, PR-1 and Others Mean and How to Fix Them
What common denial codes mean (CO-16, CO-18, CO-50, CO-97, CO-197, PR-1 and more) and how to fix each, for mental health and medical practices.
Read the guide →How to Appeal a Denied Insurance Claim: A Step-by-Step Guide for Practices
When to correct, reconsider or appeal a denied claim, what a strong appeal letter includes, Medicare's five appeal levels and deadlines, and how to track appeals.
Read the guide →Find out what your claims are leaving on the table
Tell us about your practice. We will review 90 days of claims and show you what is recoverable, at no cost.
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