02 — Capability · BC-1840.40
Claim Denials & Appeals
Recover payment that payers wrongly deny or underpay, and remove the causes so fewer denials happen next time. Pre-service authorization denials are patient access; the payer's handling of an appeal is the health plan's own work.
- Denial Management
- Denials Prevention
- Payer Appeals
In scope
- Denial categorization, work queues and root-cause analytics
- Written appeals, reconsideration requests and payer audit responses
- Underpayment detection and out-of-network payment disputes
- Payer overpayment refunds and credit balances
Out of scope
- Pre-service authorization denials (see BC-1810.40)
- Health plan appeals, grievances and payment disputes (see BC-1870.40)
- Conducting prepayment and postpayment audits as a payer (see BC-1870.60)
Realized by · 3
- Epic · Revenue Cyclecore via BC-1840.40.10
- Oracle Health · Contract Managementstrong via BC-1840.40.40
- MEDITECH Expanse · Revenue Cyclecore via BC-1840.40.10
Used in · 2
Build it · 1
Decomposes into · 6
- BC-1840.40.10Denial Work QueuesSort every denial by reason, payer and value into queues for the team that can fix it, and track each one to recovery or write-off.
- BC-1840.40.20Denial Root-Cause AnalyticsTrace denials to the step that caused them, from registration to coding, and drive fixes upstream so the same denial stops recurring.
- BC-1840.40.30Payer Appeal SubmissionWrite and submit appeals and reconsideration requests with the supporting record within the payer's deadline, and escalate through each appeal level.
- BC-1840.40.40Underpayment RecoveryCompare each payment with the contracted amount, and pursue every variance worth the effort with the payer, including out-of-network payment disputes through independent dispute resolution.
- BC-1840.40.50Payer Overpayment RefundsFind and resolve credit balances and payer overpayments, and return money owed within the time the rules allow.
- BC-1840.40.60Payer Audit ResponseAnswer payer and government audits and additional documentation requests with the right records on time, track each finding and appeal those that are wrong.