Denial Management Services

Denial Categories We Work

Denials are categorized by CARC and RARC codes and grouped into actionable buckets so the practice can see which upstream workflow is generating the loss — not just a flat denial total.

• Eligibility and coverage denials (CO-27, CO-26, CO-31)
• Medical necessity denials (CO-50) with LCD/NCD review
• Prior authorization denials (CO-197) and retroactive auth workflows
• Coding-related denials (CO-11, CO-16, CO-18) including bundling and modifier rejections
• Timely filing (CO-29) and credentialing (CO-B7) denials
• Coordination of benefits and duplicate-claim denials

Appeal Discipline

Each denial type has a documented appeal template, supporting documentation checklist and tracked turnaround target. Appeals are escalated to payer provider relations when initial responses fall outside contractual timeframes. Recovery rate by denial category is tracked and reported monthly.

• Payer-specific first, second and external appeal workflows
• Clinical documentation pulled and packaged with appeal letters
• Tracked appeal status against payer SLA windows
• Recovery rate measured by denial category and payer

Prevention — The Higher-Leverage Half

Recovering a denial is reactive; preventing it is structural. We translate denial trend data back into concrete fixes — front-desk eligibility script changes, coder education on specific CPT/ICD-10 combinations, prior auth workflow updates and provider documentation feedback — so the same denials don't refile next quarter.