Denial Management Services

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• What are the most common reasons claims are denied?

  Eligibility and coverage problems, missing or invalid prior authorization, coding and medical-necessity mismatches, missing or incomplete information, duplicate submissions, and timely filing. The pattern worth noticing is that most of them are decided before the claim is ever created, which is why denial work that stops at the appeal keeps producing the same denials.

• What is the difference between correcting a denial and appealing one?

  A correction admits the claim was wrong — the wrong code, a missing modifier, the wrong payer — so it is fixed and resubmitted. An appeal disputes the payer's decision on a claim that was right, and needs supporting documentation filed inside the payer's appeal window. Sending an appeal where a correction was needed simply spends the window.

• What is root-cause denial analysis?

  Grouping denials by reason code, payer, provider and procedure until the pattern behind them is visible, then fixing the upstream step that produces it. Working a denial recovers one claim; identifying that the denials share a registration field, a modifier, or one payer's authorization rule prevents the next batch.

• How long is there to appeal a denied claim?

  The appeal window is set by the payer and the contract, and it is usually shorter than the original filing limit — often counted from the remittance date rather than the date of service. That is why unposted remittances and unworked denial queues are costly: the deadline runs whether or not anyone has looked at the denial.

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