Every denied claim is revenue you have already earned, sitting behind a payer decision.
Premium Medical Billing Solutions works those denials for you. We find out why
each claim was denied, correct or appeal it, follow up with the payer, and
trace repeat denials to their source so they stop recurring.
Reviewed by our certified medical billing and coding team.
Denial management is the work of tracking, correcting, appealing, and analyzing claims that payers have denied, then using the pattern behind those denials to prevent them. It has two jobs: recovering revenue from claims already denied, and fixing the eligibility, authorization, coding, documentation, or submission problems that caused them.
Two terms are often mixed up. A rejected claim is stopped before the payer adjudicates it, usually for a data or formatting problem, and is fixed and resubmitted. A denied claim was processed, and the payer decided not to pay all or part of it. The remittance advice (ERA or EOB) explains why through claim adjustment reason codes (CARCs) and remark codes (RARCs), and the right response depends on which codes appear.
These are hospital-heavy datasets, so your numbers will vary by specialty and payer mix. That is why we start with your remittance data rather than an industry average.
We pull denials from your ERAs, EOBs, and payer portals and sort them by payer, provider, service, and CARC/RARC. Rejections, true denials, and contractual adjustments are separated so effort goes where money can actually be recovered.
We look past the code to what produced it: an eligibility gap at check-in, a missing authorization, a modifier error, thin documentation. Repeat denials from the same source are flagged for correction upstream instead of being reworked claim by claim.
Denials caused by fixable errors, such as missing or invalid claim data, are corrected and resubmitted inside payer filing limits.
For denials worth contesting, we assemble the appeal: the payer’s stated reason, the relevant policy criteria, and supporting clinical documentation gathered with your providers. We submit in each payer’s required format and confirm receipt.
We track every appeal and resubmission to resolution, follow up when payers go quiet, and escalate to the next appeal level when the case merits it.
If denied or rejected claims are sitting in your accounts receivable, we review them and work those still within filing and appeal deadlines.
We report denial trends and results, and we give your front desk, coders, and providers specific feedback and training on documentation, coding guidelines, and payer policies.
Appealing everything wastes effort, and writing off everything wastes revenue. This is how we sort common denial types.
Denial type |
Example code |
Typical response |
|---|---|---|
Contractual adjustment
|
CO-45: charge exceeds the fee schedule or contracted arrangement
|
Usually a contractual write-off. We check the allowed amount against your contract and dispute it as an underpayment if it does not match.
|
Missing or invalid claim information
|
CO-16, paired with a remark code that names what is missing
|
Correct the data and resubmit. An appeal is usually not needed.
|
Medical necessity
|
CO-50
|
Appeal with clinical documentation mapped to the payer's coverage criteria.
|
Missing authorization
|
CO-197: precertification or authorization absent
|
Confirm whether authorization existed or can be obtained under the payer's rules, then fix the front-end step so it does not repeat.
|
Timely filing
|
CARC 29: filing time limit expired
|
Usually appealable only with proof of timely original submission.
|
Our Denial Code Glossary explains each code, including CO-45 and CO-50.
For Original Medicare fee-for-service, a redetermination request is due within 120 days of receiving the notice, and a reconsideration by a Qualified Independent Contractor within 180 days of the redetermination. The Medicare contractor must decide a redetermination within 60 days. Medicare Advantage, Medicaid, and commercial plans set their own appeal levels and deadlines. Late appeals are usually dismissed unless good cause is shown, so we track each payer’s deadline from the day a denial posts. Centers for Medicare & Medicaid Services CMS
Prior authorization denials are changing too. CMS’s prior authorization final rule, with operational requirements effective January 1, 2026, applies to Medicare Advantage, Medicaid, CHIP, and federal-exchange plans, not Original Medicare or employer plans. It requires those payers to give specific information about prior authorization denials, which helps build a targeted appeal. Faxsipit CMS
confirms coverage, benefits, and authorization requirements before the visit.
secures required approvals ahead of service.
reduces code, modifier, and documentation errors.
keeps provider enrollment with payers current.
shows where your current process is losing claims.
Measure |
What it tells you |
|---|---|
Initial denial rate (by claim count and dollars)
|
Standard measures HFMA's Claim Integrity Task Force recommends for benchmarking
|
Denial rate by payer, provider, and service
|
Where the problem is concentrated
|
Top denial reasons (CARC/RARC)
|
Which fixes will pay off most
|
Appeals filed and overturn rate, by denial category
|
Whether contested denials are being won
|
Days to resolve a denial
|
How fast recoverable revenue moves
|
Denied claims in aged A/R
|
Where money is at risk of expiring
|
Definitions are set at the start, and we report actuals and trends rather than a single blended figure. Our business intelligence reporting covers aging, reimbursement, and payer mix analysis.
We work with private practices, group practices, urgent care centers, clinics, imaging centers, and healthcare systems across the United States. It fits best when:
A denial management company reviews denied claims, finds out why each was denied, corrects or appeals the ones that can be recovered, follows up with payers, and reports patterns back to you. At Premium Medical Billing Solutions that includes feedback and training for your staff so the same errors stop recurring.
It depends on the payer. For Original Medicare fee-for-service, a first-level appeal (redetermination) is due within 120 days of receiving the initial determination. Medicare Advantage, Medicaid, and commercial plans set their own limits through contracts and rules, so we track the deadline for each payer from the day a denial posts.
Denials the payer likely decided in error are worth pursuing, such as a medical necessity denial that the chart supports or a timely filing denial where you can prove on-time submission. Contractual adjustments that match your contract are usually written off. We sort denials by likelihood of recovery and dollar value before committing effort.
HFMA describes an industry average of 5% to 10%, with under 5% as optimal. Definitions differ: some measures count claims, others dollars, and some count only actionable denials. We agree on the definition with you before we report, so comparisons are like for like.
Yes. We review denied and rejected claims already in your accounts receivable and work the ones still within filing and appeal deadlines. Older claims may be past recovery, which is why an early review matters.
We work with your providers to collect the clinical documentation the payer's coverage criteria call for, then build the appeal around those criteria instead of sending a generic resubmission. Your clinicians supply the clinical detail; we handle assembly, submission, and follow-up.
Copyright © 2026 Premium Medical Billing Solutions LLC. All rights reserved.
