A denied claim is not lost money, it is unworked money, and it stays that way only until the payer's appeal window closes. Our denial management services read every denial by its reason code the day it posts, choose between a corrected claim and a formal appeal, file inside the deadline and report back which step in your practice produced it. The difference between denial management that lowers your denial rate and denial management that only reports it is whether anybody fixes the cause upstream.
Worked by reason code, not by age
Every denial is triaged by its claim adjustment reason code and any accompanying remark code, because the code determines the remedy. CO-16 says the claim lacks information, and the RARC beside it says what: N286 is a missing or invalid referring provider, M51 a missing or invalid procedure code, N382 a patient identifier problem. CO-4 says the procedure code is inconsistent with the modifier, which is usually a missing modifier 25 or 59. CO-97 says the payment for this service is included in another service, an NCCI bundling edit. CO-50 is medical necessity. CO-29 is timely filing. CO-197 is a missing authorization. CO-18 is a duplicate. Sorting a queue by dollar value or age without reading these codes is how practices end up re-denying the same claims.
Corrected claim or appeal
Not every denial is an appeal. A CO-16 with an M51 remark is a corrected claim: fix the code, resubmit with claim frequency code 7 and the original claim number, done in a day. Filing a formal appeal there wastes the appeal window and the payer's patience. A CO-50 medical necessity denial or a CO-97 where the modifier was correct is an appeal, and it goes out with the payer's own medical policy quoted, the NCCI edit table reference where bundling is in dispute, the operative or progress note and a cover letter that addresses the stated reason in the first paragraph. Generic appeal letters are read as generic. A CO-29 timely filing denial is neither: it needs the clearinghouse 277CA acceptance report proving the payer received the claim on time, which is why we keep those reports for every claim.
Medicare appeals and their deadlines
Medicare fee-for-service has five appeal levels, and the first two carry the deadlines that matter for a practice. A redetermination request goes to your MAC within 120 days of the initial determination on the 835, and the MAC generally decides within 60 days. If it is upheld, a reconsideration goes to the Qualified Independent Contractor within 180 days of the redetermination notice, and any documentation not submitted by then can be excluded later. Beyond that are the Administrative Law Judge hearing, the Medicare Appeals Council and federal court, each with its own minimum amount in controversy. Medicare Advantage and commercial plans set their own windows, commonly 60 to 180 days from the remittance, and they are printed on the denial letter or the provider manual. Every denial in our queue carries the deadline that applies to it, and the queue is worked in that order.
Fixing the cause upstream
A denial is the last visible symptom of a problem that started earlier, and the code points at where. CO-27, CO-22 and CO-31 come from registration and belong to eligibility verification. CO-4, CO-97 and CO-50 come from documentation and coding and are fixed by coders and providers together, sometimes with a targeted coding audit. CO-197 belongs to prior authorization. CO-29 is almost always a claim submission or follow-up failure. The monthly denial trend report names the source of each recurring code, with volume and dollars attached, so you can see which fixes belong to us and which need a change in your own workflow.
How denial management runs week to week
Remittances are posted daily, and every denied line is logged the day it posts with its CARC and RARC codes, the payer, the dollar amount and the deadline that applies. The queue is then worked in a fixed order: anything close to an appeal or filing deadline first, then denials that can be fixed with a corrected claim, then appeals that need documentation pulled from the chart. Each denial carries a status and a next action until it is paid, adjusted with a stated reason, or written off with your approval. Weekly reporting shows what came in, what was resolved and what is still open by reason code, and the monthly review goes through the trend.
Signs your denials are being reported rather than worked
A denial rate that is stable month after month is the first sign. If the same reason codes appear at the same volume every month, nothing upstream is being fixed. Ask your current vendor for the appeal log: the date each appeal went out, the level, and the outcome. If the log does not exist, appeals are not being tracked. Ask what share of denials were resolved with a corrected claim versus a formal appeal; a vendor that appeals everything is wasting appeal windows. Ask for the write-off list with a reason on every line. Denials written off as uncollectible without a reason are usually denials nobody worked before the deadline passed. The free billing audit runs this check on your last 90 days of remittances.
What Is Included
- CARC and RARC triage the day the 835 posts
- Corrected claim or formal appeal, chosen by reason code
- Appeal letters citing the payer's own policy
- Medicare redetermination and reconsideration filings
- Proof of timely filing from clearinghouse records
- Monthly denial trend report with the source named
| Reason code standard | Claim adjustment reason codes (CARC) and remittance advice remark codes (RARC) are maintained by X12 and required on the 835Source: X12, Claim Adjustment Reason Codes |
|---|---|
| Medicare first-level appeal | Redetermination must be requested within 120 days of the initial determination; the MAC generally decides within 60 daysSource: CMS, First Level of Appeal: Redetermination |
| Medicare second-level appeal | Reconsideration by a Qualified Independent Contractor must be requested within 180 days of the redetermination decisionSource: CMS, Second Level of Appeal: Reconsideration |
| Medicare filing limit | Claims must reach the MAC no later than one calendar year after the date of serviceSource: CMS MLN, Medicare Billing: CMS-1500 and 837P |
Denial Management & Appeals: Common Questions
Both, though old denials are scoped separately because some are past appeal deadlines and are not recoverable. We tell you which is which before starting rather than billing you to chase claims that cannot be paid.
A rejection was stopped before the payer adjudicated it, usually at the clearinghouse or in the payer's front-end edits, and shows up on a 277CA rather than an 835. It can be corrected and resent. A denial was adjudicated and refused, appears on the 835 with a CARC, and needs either a corrected claim or an appeal.
That depends on what is causing your denials. If they are coding and documentation issues we can fix them; if they are front-desk registration errors, the fix involves your staff and we will tell you so. We would rather set that expectation than promise a number.
It is logged the day the remittance posts and prioritized by deadline rather than by dollar value. Denials with a short appeal window are worked first, because a large balance with time left on it is safer than a small one about to expire.
Yes, for appeals on medical necessity or level of service, because the appeal has to quote the note. Access is role-based, covered by the signed BAA, and logged, and it is limited to the records the appeal requires.
Open denials are inventoried during the free A/R review so nothing expires while responsibility is changing hands. During the parallel run we work new denials while your current process winds down, and you can see both queues.