Denial Management and Appeals
We work every denial a practice receives: read the reason the payer gives, correct and resubmit the claim or appeal it in writing inside the payer’s window, and follow it until it is paid or closed with a documented reason. Then we fix what caused it, so the same denial does not come back.
What Denial Management Covers
Denial management is the work of finding out why a payer refused to pay a claim, getting it paid by correcting it or appealing it, and changing what happens before submission so the same denial does not recur. Three outcomes look alike on an aging report, and each needs different handling.
| What happened | What it means | What we do |
|---|---|---|
| Rejected | The clearinghouse or the payer’s front-end edits stopped the claim before it was processed, usually for a missing or invalid field. There is nothing to appeal. | Correct the field and send the claim again. The filing deadline still applies. |
| Denied | The payer processed the claim and refused it, with a reason code on the remittance. | Correct and resubmit where the payer accepts a corrected claim; otherwise request a reopening or file a written appeal. |
| Underpaid | The payer processed the claim and paid less than the contracted amount. | Flag it against your fee schedule when the payment is posted, and ask the payer to reprocess it or appeal. |
How We Work a Denial
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Read the reason
Every denial is reviewed by payer and by the reason and remark codes on the remittance, so the action answers the reason the payer actually gave.
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Choose the route
A fixable error is corrected and resubmitted. For Medicare, a clerical error goes through a reopening rather than an appeal. A denial on the merits is appealed. An amount that is the patient’s responsibility moves to patient billing.
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Appeal and follow through
Appeals carry the documentation that answers the stated reason and go out before the payer’s deadline. Our billers use Canis AI models to prioritize work queues and prepare appeals, and a biller approves every appeal before it is sent. Each denial is followed until it is paid or closed with a documented reason.
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Stop it coming back
Denials are reported every month by payer and reason, and the fix goes where the problem started: eligibility and authorizations at the front desk, a documentation question for the provider, or a coding edit before submission.
Common Denial Reasons and Where They Are Fixed
Payers explain a denial with a standard claim adjustment reason code from the X12 code list, usually paired with a remark code that gives the detail. These are common ones, in the code list’s own words.
| Code, and what the remittance says | Where it is fixed |
|---|---|
| 16 “Claim/service lacks information or has submission/billing error(s).” | Billing. The remark code on the same line names what is missing; it is added and the claim is resubmitted. |
| 27, 31 “Expenses incurred after coverage terminated.” “Patient cannot be identified as our insured.” | Front desk. Coverage is checked before the visit; after a denial, the current plan is found and billed. |
| 22, 109 “This care may be covered by another payer per coordination of benefits.” “Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.” | Registration. The order of coverage is confirmed and the claim goes to the right payer. |
| 197 “Precertification/ | Before the visit. Authorizations are tracked; when one was obtained or was not required, the denial is appealed with the proof. |
| 50 “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.” | Documentation. The denial is appealed with the records that show why the service was needed, and any documentation gap goes back to the provider. |
| 4, 11, 97 “The procedure code is inconsistent with the modifier used.” “The diagnosis is inconsistent with the procedure.” “The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.” | Coding. Codes and modifiers are checked against the note before submission; a supported modifier is defended on appeal, and an unsupported one is corrected. |
| 18 “Exact duplicate claim/service” | Follow-up. The original claim’s status is checked before anything is sent again. |
| 29 “The time limit for filing has expired.” | Filing. Appealed only with proof the claim was filed on time. A plan regulated by New York must also reconsider some late claims; see A/R recovery. |
Each line of a remittance also carries a group code. PR, patient responsibility, means the amount can be billed to the patient. CO, contractual obligation, means it cannot, so it is corrected, appealed, or written off with the reason recorded.
The Deadlines That Decide an Appeal
A late appeal is dismissed unless the payer accepts a reason for the delay, so the deadline matters as much as the argument. These are the windows for Original Medicare and for plans regulated by New York.
Original Medicare (Part A and Part B)
| Step, and who decides | Deadline to file |
|---|---|
| Reopening Medicare Administrative Contractor | Within 1 year of the initial determination for any reason, or 4 years for good cause. Clerical errors, including minor errors and omissions, are corrected this way rather than by appeal. |
| 1. Redetermination Medicare Administrative Contractor | 120 days from receiving the initial determination, which is presumed to arrive 5 days after the date on the notice. The contractor has 60 days to decide. |
| 2. Reconsideration Qualified Independent Contractor | 180 days from receiving the redetermination. The contractor has 60 days to decide. |
| 3. Hearing Administrative law judge, Office of Medicare Hearings and Appeals | 60 days from receiving the reconsideration, if at least $200 is in dispute (the amount for 2026 and 2027). |
| 4. Council review Medicare Appeals Council | 60 days from receiving the hearing decision. |
| 5. Judicial review Federal district court | 60 days from receiving the Council’s decision, if at least $1,960 is in dispute in 2026, or $2,000 in 2027. |
Plans regulated by New York
| Situation | The rule |
|---|---|
| The plan decides after the visit that a service was not medically necessary | The practice can appeal on its own behalf. The plan must allow at least 45 days to file, acknowledge the appeal within 15 days, and decide within 30 days of receiving the information it needs. If it misses its deadline, the denial is reversed. (Insurance Law § 4904) |
| The plan upholds that denial on appeal | The practice can request an external appeal through the Department of Financial Services within 60 days of the plan’s final adverse determination. The plan may charge the practice up to $50, refunded if the denial is overturned. (Insurance Law §§ 4910, 4914) |
| A claim is denied only because it was filed late | The practice can ask for reconsideration by showing an unusual occurrence and a pattern of filing on time. The plan may reduce payment by up to 25 percent, and may deny in full a claim filed 365 days or more after the service. (Insurance Law § 3224-a(h)) |
Medicare Advantage plans and self-funded employer plans follow federal rules and their own agreements, and their denial letters state the appeal window. For filing deadlines and claims that were never paid, see aging A/R recovery.
Sources: CMS, Original Medicare (fee-for-service) appeals, with the third-level and fifth-level pages for the amounts in dispute; 42 CFR 405.942, 405.950, 405.962, 405.970, 405.1014, 405.1102 and 405.980; New York Insurance Law § 4904, § 4910, § 4914 and § 3224-a; New York State Department of Financial Services, external appeals; reason and group codes from X12, Claim Adjustment Reason Codes. Checked November 12, 2026.
What You See Each Month
A Denial Report
Denials by payer and reason, every month, so you can see which rule is costing you money and whether the same denial is coming back.
One Monthly Report
Charges, collections, denial rate, payer turnaround and aging on one report, with a quarterly review of the trend.
Checks Before Submission
Eligibility and authorizations before the visit, coding review against the note, and claim scrubbing against payer edits. Canis AI scores denial risk; a biller reviews and submits.
To measure your own numbers, use the free denial rate calculator. Our guide to billing metrics explains what the denial rate shows and what it leaves out.
Denials by Specialty
Some denials come from a specialty’s own rules, and each specialty page covers them:
- Podiatry: routine foot care coverage, class findings and the treating physician’s visit date.
- Behavioral health: carve-out routing and parity-suspect denials.
- Primary care: modifier 25 and preventive visits billed with problem visits.
- Workers’ compensation: objections from the carrier instead of denial codes.
Denial Management FAQ
What is denial management in medical billing?
Denial management is the work of finding out why a payer refused to pay a claim, getting it paid by correcting it or appealing it, and fixing the cause so the same denial does not recur. It starts with the reason and remark codes on the remittance and ends when the claim is paid or closed with a documented reason.
What is the difference between a rejected claim and a denied claim?
A rejected claim was stopped before the payer processed it, usually by the clearinghouse or the payer’s front-end edits for a missing or invalid field. It is corrected and sent again, and the filing deadline still applies. A denied claim was processed and refused, with a reason code on the remittance. It is corrected, reopened or appealed, depending on the reason and the payer.
How long do you have to appeal a Medicare denial?
For Original Medicare, 120 days from receiving the initial determination to request the first level, a redetermination by the Medicare Administrative Contractor. The notice is presumed to arrive 5 days after its date. After that, a reconsideration must be requested within 180 days, and a hearing, a Council review and federal court each within 60 days. A clerical error is corrected through a reopening instead, which can be requested within a year for any reason.
Can a practice in New York appeal a denial on its own behalf?
Yes, with plans regulated by New York. When a plan decides after the service that it was not medically necessary, the practice can appeal on its own behalf. The plan must allow at least 45 days to file and decide within 30 days of receiving the information it needs, and if it misses its deadline the denial is reversed. After the plan’s final denial, the practice has 60 days to request an external appeal through the Department of Financial Services. The plan may charge up to $50, which is refunded if the denial is overturned.
Should every denial be appealed?
No. A denial caused by a fixable error is corrected and resubmitted. An amount that is the patient’s responsibility goes to patient billing. A denial that is correct is closed with the reason written down. What gets appealed is a denial on the merits that the record can answer, and the appeal has to be filed inside the payer’s window.
How do you prevent denials?
By checking before submission: eligibility and authorizations before the visit, coding and modifier review against the documentation, and claim scrubbing against payer edits, where Canis AI validates codes and scores denial risk and a biller reviews and submits. A monthly denial report by payer and reason shows what still gets through, so the cause can be fixed where it starts.
Contact Us
Request a Free Baseline Review
Tell us your specialty, how many providers you have, who handles billing today, and the EHR or billing system you use. We sign a business associate agreement before you send any reports, then look at your denial rate, days in A/R, aging balances and payer mix, and come back with where claims are being denied or left uncollected and what we would change.
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