Denial management services
Denial management is the work of finding out why a payer refused a claim, correcting or appealing it, and fixing the cause so the same denial does not come back.
Denial decoder
Public codesPick the reason code from your remittance.
CO-16Denied: processed, then refused
The claim is missing information or has a billing error.
- Cause
- Patient and coverage details
- How it’s worked
- Corrected and resubmitted
- Worth knowing
- A remark code on the same line says what is missing, such as a referring provider or a valid member ID.
CO means the amount is the practice’s to resolve under its contract, not the patient’s to pay. The same reason codes also come with PR (patient responsibility) or OA (other adjustment).
Rejected or denied? The difference decides the fix.
Both stop a claim from being paid, but they happen at different points and need different work.
Claim sent
Coded, checked and submitted, usually through a clearinghouse.
Front-end checks
The clearinghouse and the payer check the data before processing it.
Rejected. The claim failed the clearinghouse or payer checks before it was processed, usually for missing or invalid data. It is corrected and sent again. There is nothing to appeal yet.
Processed
The payer adjudicates the claim against the plan and its rules.
Denied. The payer processed the claim and refused to pay all or part of it. It needs a correction, a reconsideration or a formal appeal, within that payer’s deadline.
Paid
Payment and the remittance reach the practice and are posted.
Paid first time. The aim for every claim. Most of the work to get here happens before the claim is sent.
Why claims get denied
Each cause has its own reason codes. Pick one to read it in the decoder.
Coding errors
Codes the documentation does not support, missing modifiers, or procedures that do not match the diagnosis.
Patient and coverage details
A wrong member ID, coverage that lapsed, or details that do not match the payer’s records.
Bundling and unbundling
Services billed separately that the payer pays as one, or one service split into several.
Missing authorization
Services that needed a prior authorization or referral the claim cannot show.
Late filing
Claims that reached the payer after its timely-filing limit.
Medical necessity
Services the payer decided the record does not show were needed.
The denial management process, step by step
Find the real cause
We read the remittance and the denial codes, not just the headline reason, and confirm what actually went wrong.
Route it to the right specialist
Each denial is grouped by cause and handed to the person who fixes that kind of problem: coding, eligibility or payer follow-up.
Correct, resubmit or appeal
What can be fixed is corrected and resubmitted. What the payer got wrong is appealed, with the documentation the appeal needs.
Follow up until it is resolved
Open denials are tracked and chased with the payer until the claim is paid or closed with a reason.
Fix the cause upstream
Repeat denials are traced back to eligibility, coding or documentation, and the step that caused them is changed.
Free tool
What are denials costing your practice?
A few numbers you already know. See the rework cost and what never comes back, with every assumption shown.
Open the calculator- Claims a month
- 1,000
- Denial rate
- 7.5%
- Average paid
- $120
Related billing services
- Claims submissionCharges entered, scrubbed and submitted clean, then tracked to a decision.
- A/R follow-upUnpaid claims worked by age and value until they are paid or closed.
- Eligibility verificationCoverage and benefits checked before the visit, so claims do not fail on eligibility.
- Auditing & complianceRegular reviews of coding and billing against payer and CMS rules.
Denial management questions
What is the difference between a rejected claim and a denied claim?
How long do we have to appeal a denied claim?
Will we see why our claims were denied?
Find out what denials are costing your practice.
Unsure how much revenue you are missing? Start with a complimentary billing audit.
Free consultation