Skip to main content
Medclaim Services Logo

Menu

Free Billing Audit

Services

Denial Management Services

Every denial points to a step in the revenue cycle that went wrong. We correct and resubmit what can be fixed, appeal what was wrongly denied, and trace recurring denials back to the registration, authorization, coding or documentation problem that caused them.

  • Denials categorized by group code, CARC and RARC, and payer
  • Appeals written to the payer's own policy and filed before deadlines
  • Prevention rules added so the same denial does not come back
Request a Free Billing Audit

How we work a denial

  • Daily triage

    New denials from each remittance are sorted the same day by reason, value and appeal deadline, so the most time-sensitive ones are worked first.

  • Corrected claims

    Fixable errors are corrected and sent as replacement claims using claim frequency code 7, or voided with code 8, rather than as duplicates.

  • Written appeals

    Appeals cite the payer's coverage policy, the contract and the documentation, and include only the records needed to support the service.

  • Medicare appeals

    Medicare denials follow a five-level process, starting with redetermination by the MAC (requested within 120 days) and reconsideration by a Qualified Independent Contractor.

  • Root-cause tracking

    Each denial is tagged to the step that caused it, such as eligibility, authorization, coding or documentation, so trends show where to fix the process.

  • Write-off controls

    Denials are only adjusted off under rules you approve, so revenue is never written off simply because an appeal deadline passed.

Official sources: CMS Blue Button: claim frequency code (external site), CMS: Original Medicare appeals (external site), eCFR: 42 CFR 405.942 (redetermination time frame) (external site), CMS: health care payment and remittance advice (external site)

The denial cycle, step by step

  1. Step 1: Read the remittance

    Group code, CARC and RARC are read together; the remark code usually explains what the payer actually wants.

  2. Step 2: Decide: fix, appeal or adjust

    Correctable errors are resubmitted, payer errors are appealed, and true non-billable items are adjusted under your policy.

  3. Step 3: Track to resolution

    Every reworked claim is followed until it pays or the appeal is decided, with each step recorded.

  4. Step 4: Prevent the repeat

    Recurring causes become scrubber edits, front-desk checklist items or provider documentation tips.

Signs you need denial help

  • Denials are piling up unworked

    If denials sit in a queue for weeks, some will pass their appeal deadlines.

  • The same denials keep coming back

    Recurring reasons mean the cause upstream has not been fixed.

  • Appeals are rarely won

    Generic appeal letters that do not address the payer's actual policy tend to fail.

Frequent denial codes and what they usually mean

Claim adjustment reason codes (CARCs) appear with a group code such as CO or PR. These are among the most common, with the fix we usually start with.

Common claim adjustment reason codes, their usual meaning and typical fix
CodeWhat it usually meansWhere we start
CO-16The claim is missing information or has a submission error; the RARC says what.Correct the missing or invalid data and resubmit.
CO-197Precertification, authorization or notification was absent.Check whether an approval existed; if so, appeal with it attached.
CO-50The payer considers the service not medically necessary.Compare the diagnosis and documentation with the payer's coverage policy, then appeal.
CO-97The service is included in the payment for another service.Check NCCI and payer bundling rules; use a modifier only if the service was truly distinct.
CO-29The time limit for filing has expired.Look for proof of timely filing, such as clearinghouse acceptance reports.
CO-22Another payer may be primary under coordination of benefits.Confirm coverage order with the patient and payers, then rebill correctly.
CO-18Exact duplicate claim or service.Check the original claim's status before sending anything again.

Code meanings are summarized from the published CARC list. Payers can use the same code for slightly different reasons, so the RARC and payer policy decide the fix.

Frequently asked questions

How long do we have to appeal a denial?

It depends on the payer. Commercial contracts and payer manuals set their own limits, while a Medicare redetermination must be requested within 120 days of receiving the initial determination.

What do the CO and PR group codes mean?

CO (contractual obligation) puts the financial responsibility on the provider, and PR (patient responsibility) puts it on the patient, such as a deductible. Other group codes describe other kinds of adjustments.

Should every denial be appealed?

No. Many denials are faster to fix with a corrected claim than an appeal, and some low-value denials cost more to work than they return. Clear rules on what to fix, appeal or adjust keep effort on the denials that recover the most.

How do you stop the same denials from coming back?

By tagging each denial to the step that caused it and changing that step: a new scrubber edit, an eligibility check at scheduling, an authorization trigger or a documentation reminder for providers.

Can you work denials from before we started with you?

Open denials that are still within their appeal window can usually be included in onboarding. Including them is part of our standard onboarding, priced within your agreement.

Related services and specialties

See all services

Find the root cause of your denials

A free audit groups your denials by reason code and payer, and shows which fixes would prevent the most of them.

Request a Free Billing Audit