Denial management services
Every denial worked, and the cause fixed upstream.
We sort every denial by its reason code, correct and resubmit what can be fixed, appeal the rest with the right records inside the payer’s deadline, and change the step that caused it so the same denial stops coming back.
- Denials worked
- Within 48 hours
- Appeals
- Written, with records
- Tracked by
- Payer & reason code
- Price
- Included in billing
Why a denial costs more than the claim
A denied claim is paid late, if it is paid at all. Someone has to read the remittance, find the problem, fix it, and resubmit or appeal before the deadline, and every payer sets its own deadline. When that work waits for a quiet week, claims age past the point where they can be recovered.
Most denials repeat. The same missing authorization, modifier or eligibility gap comes back month after month until someone changes the step that causes it. That is the part of denial management most billing teams skip, and the part we report on.
How we work every denial
Sort by reason code
Each denial is grouped by payer and by its claim adjustment reason code (CARC) and remark code (RARC), so we know at once whether it needs a correction, an appeal or a call.
Correct and resubmit
Missing information, wrong modifiers, and eligibility or coordination-of-benefits errors are fixed and sent back as corrected claims.
Appeal with evidence
Medical-necessity, authorization and bundling denials get a written appeal with the chart notes, authorization records and payer policy that support payment.
Track to payment
Every appeal goes on a calendar against that payer’s deadline and is followed up until it is paid or closed with a reason.
Fix the cause
We show you the patterns behind your denials and change the step that causes them: eligibility checks, authorizations, coding or charge entry.
Common denials and how we fix them
The reason codes that show up most on remittances, what they mean and the usual fix.
- CO-16: missing informationFind the missing or invalid field, correct it and resubmit.
- CO-197: no prior authorizationRequest a retro authorization where the payer allows one, or appeal when the service was urgent.
- CO-50: not medically necessaryAppeal with the notes, the diagnosis and the payer’s coverage policy, such as a Medicare LCD.
- CO-97: bundled into another serviceCheck the edit, then appeal or add a modifier only when the documentation supports a separate service.
- CO-22: another payer is primaryConfirm the coverage order with the patient and payers, then bill the primary payer first.
- CO-27: coverage had endedCheck eligibility for the date of service and bill the right payer or the patient.
- CO-29: filing deadline passedAppeal with proof of timely filing, such as clearinghouse acceptance reports.
- OA-18: duplicate claimCheck the original claim’s status before anything is resubmitted.
Look up a denial code
Each of these codes has its own page: what it means, why it happens and how to clear it.
CO-16
Missing or invalid claim information. The remark code names the field; fix it and resubmit.CO-97
Bundled into another service already paid. Check the edit and the notes before adding a modifier.CO-45
Your charge exceeds the allowed amount. Usually a write-off; a problem when the allowed is below contract.CO-22
Another payer may be primary under coordination of benefits, so that payer has to be billed first.CO-197
The plan required precertification, authorization or notification and found none for this service.All denial codes
The full list, grouped by what the payer is telling you.
Appeal deadlines we track for you
Medicare gives you 120 days from receiving the initial determination to ask for a redetermination, the first level of appeal. If that fails, you have 180 days from the redetermination decision to ask a qualified independent contractor for reconsideration.
Commercial payers and Medicaid plans set their own windows in the provider manual and your contract, and some are much shorter. So every denial goes on a calendar the day it posts, with the deadline for that payer next to it.
Stopping denials before the claim goes out
The cheapest denial is the one that never happens. Most preventable denials start before the visit or at charge entry, so that is where our fixes land:
- Eligibility and benefits confirmed before the visit, with eligibility verification
- Authorizations secured and logged before the service, through prior authorization
- Codes and modifiers checked against the notes by certified medical coders
- Claims scrubbed against each payer’s edits before they are submitted
- Front-desk and charge-entry steps changed when a pattern shows up in the denial report
Each month’s denial report shows which step caused the denials we worked, so you can watch your denial rate fall instead of taking our word for it.
What your practice gets
- Denials worked within 48 hours of posting, not batched monthly
- Corrected claims and appeals written by billers who know your payers
- A monthly denial report by payer, reason code and provider
- Fixes fed back to your front desk, authorizations and coding
- Old denials and aged A/R worked as a one-time project if you need it
- Included in our full-service rate of 3% to 6% of collections
Send us a sample of your denials. We’ll show you the pattern behind them, free.
A rejection comes back before the claim is processed, usually from the clearinghouse or payer for a format or data error, and is fixed and resent. A denial is a processed claim the payer refused to pay, and it needs a corrected claim or an appeal.
Within 48 hours of the denial posting. We don’t batch them once a month, because the appeal window keeps running while a denial waits.
Most of them: medical necessity, authorization, bundling, coordination of benefits, and timely filing when you can prove the claim went out on time. Denials caused by an error on the claim are usually fixed faster with a corrected claim than with an appeal.
120 days from receiving the initial determination to request a redetermination, and 180 days from the redetermination decision to request reconsideration by a qualified independent contractor. The later levels have their own deadlines and dollar thresholds.
Both. Appeals recover the money; prevention stops the next one. We trace each denial to the step that caused it, such as a missed eligibility check, a missing authorization or a modifier, and change that step with your team.
Yes. We can take an old denial and A/R backlog as a one-time project, oldest and largest balances first, either before we take over your billing or alongside your own team.
It is part of our full-service billing, at 3% to 6% of monthly collections with no setup or onboarding fees, together with eligibility checks, prior authorizations, coding, claims, payment posting and A/R follow-up. For a one-time clean-up of old denials, we quote after a free review of a sample.
Specialties we work with
From our guides
How to calculate days in A/R
The formula with a worked example and a calculator, the benchmarks, why a good average can hide old claims, and the fixes that bring days in A/R down.
How much do medical billing services cost?
The four ways billing companies price their work, the fees that sit outside the rate, and in-house arithmetic built from BLS data, so you can compare quotes on your own numbers.
Send us your last 90 days of A/R.
We’ll tell you what’s collectable and what’s at risk, free.