Denial Management
Denial reasons by stage, appeal review, and overturn outcomes — last 30 days
Denials this period
420
of 11,043 claims
Denial rate
3.8%
-1.4 pts vs prior
Dollars denied
$317,091
$248,404 recovered
Appeal overturn rate
78.3%
level-1 appeals
Denials by revenue cycle stage
Select a stage to see the payer reason codes driving it
Eligibility verification
Coverage inactive, wrong payer, or benefit not applicable at the time of service.
| Code | Reason | Claims | Dollars | Overturn | Prevention | Appeal | Timeline |
|---|---|---|---|---|---|---|---|
| CO-27 | Expenses incurred after coverage terminated | 41 | $26,840 | 62% | Scrub rule added | View timeline | |
| CO-31 | Patient cannot be identified as our insured | 22 | $11,480 | 74% | Scrub rule added | View timeline | |
| CO-22 | Coordination of benefits — other carrier primary | 17 | $9,310 | 81% | Scrub rule added | View timeline |
Appeal simulator
Pick any denial reason above and choose Simulate appeal to submit it through the engine — then toggle the AI recommendations and specialist review to see how the overturn outcome moves.
Example appeal — CLM-77341
Respiratory pathogen panel, 12 targets (0202U) · UnitedHealthcare · $1,291
- Denial code
- CARC 50 / RARC N115
- Payer reason
- Medical necessity not established — LCD documentation mismatch
- Appeal level
- Level 1 — written reconsideration
- Outcome
- Full contracted amount released 11 days after the denial posted.
Evidence packet
- Signed physician order (REQ-90218)
- Encounter note, 07/21/2026 — symptom onset documented
- LCD L38988 coverage-criteria excerpt
- Resulted panel report — RSV positive, therapy changed
- Immunocompromised status attestation
Appeal timeline
- Day 0AI
Watchdog flagged CARC 50 four minutes after the 835 landed and classified it as medical necessity.
- Day 0AI
Appeal packet auto-assembled: order, chart note, LCD citation, resulted report.
- Day 0Specialist
D. Okafor rewrote the clinical argument and added the physician attestation.
- Day 0Specialist
Level-1 appeal filed the same business day the denial posted.
- Day 6AI
Automated follow-up cadence confirmed payer receipt and logged the 30-day clock.
- Day 11Payer
Denial overturned on level-1 review — corrected 835 issued.
- Day 11AI
Payment auto-posted; denial pattern fed back into the scrub engine.
Overturned — $1,291 released
11 days denial-to-payment. AI drafted and tracked; the specialist owned the clinical argument.
Policy citations behind this letter
The exact payer and coverage-policy language the engine pulled to auto-write the appeal. Select a citation to highlight the sentence it produced.
Citations are version-stamped at draft time, so an audit can reproduce exactly which policy text was in force when the appeal was filed.
Every denial feeds the scrub engine
Preventable reason codes become submission-time edits, so the same denial doesn't come back next month.