Denial Management & Appeals
Working denials by cause, inside the payer's deadline.
Denials are not one problem. They are eligibility problems, authorisation problems, coding problems and documentation problems, and each has a different fix. We classify them, work them by cause, file appeals with the documentation the payer actually asked for, and report the patterns that keep repeating.
Tools we work in
- Availity
- Waystar
- Change Healthcare
- Claim.MD
- athenahealth
- eClinicalWorks
- AdvancedMD
Works well with
Scope
What this covers
The specific work included when you engage us for this service.
- Denial classification by CARC and RARC reason codes rather than by free-text notes
- Root cause analysis, so the same denial does not return the following month
- Appeal letters drafted from the clinical record and the payer's stated reason
- Appeal levels tracked with their individual deadlines and required documentation
- Retrospective authorisation requests where the payer permits them
- Corrected claims and rebilling where an appeal is the wrong instrument
- Write-off review, so accounts are closed deliberately rather than by default
What you receive
- 01A denial queue organised by cause, value and deadline
- 02Appeal packets filed with the supporting documentation attached and logged
- 03A monthly denial report showing the leading causes and what moved since last month
Questions
Denial Management & Appeals, answered
How long do we have to appeal a denial?
It depends on the payer and the plan. Some allow a short window measured from the remittance date, others allow months, and Medicare and commercial payers differ from each other. We record each payer's appeal deadline up front and work backwards from it, because a missed deadline turns a recoverable claim into a write-off, and that is the most avoidable loss in the whole cycle.
Is it always worth appealing?
Sometimes it is not, and we will say so. If the cost of working an appeal exceeds what the payer will pay, the honest move is to write off that instance and fix the cause behind it. What we never do is let the cause repeat, because that is where the real money sits, not in any single small claim.
What is the difference between a denial and a rejection?
A rejection means the claim never entered the payer's adjudication system, usually a formatting, enrolment or data problem, and it is fixed by correcting and resubmitting. A denial means the payer adjudicated the claim and refused payment for a stated reason, and it is fixed by appeal or correction depending on that reason. The two need different work, and treating one as the other wastes time.
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Tell us where the manual work is
A 30-minute call. We map the process, tell you what we would automate or build first, and what it costs. No retainer before you agree the scope.
- No retainer before scope is agreed
- Written plan you can act on alone
- Worldwide delivery, on your hours