Services

Denial management that addresses the claim and the cause

We categorize each denial by its reason codes, review eligibility, authorization and coding gaps, support timely filing and medical necessity responses, and track trends so recurring causes can be addressed.

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Common codes in this work4 codes

Code	What it means
`CARC CO-197`	Precertification or authorization absent
`CARC CO-50`	Not deemed a medical necessity by the payer
`CARC CO-27`	Expenses incurred after coverage terminated
`CARC CO-29`	The time limit for filing has expired

CARC = claim adjustment reason code, as printed on your remittance.

A denial is two problems: the claim that needs attention, and the step that will cause the next one. Medwiser looks at both, categorizing each denial and then looking at the pattern behind it.

You can see which payers and reasons drive your denials, and which upstream steps to look at.

What's included

Denial Reason Categorization (CARC/RARC)Each denial is categorized by its claim adjustment reason code (CARC) and remittance advice remark code (RARC).
Eligibility & Authorization GapsDenials tied to coverage or missing authorizations are identified, along with the step that missed them.
Coding/Modifier ReviewCoding and modifier issues are reviewed against provider documentation.
Timely Filing & Medical Necessity SupportSupport for denials based on filing limits or medical necessity, including the documentation the payer asks for.
Root-Cause Denial Trend AnalyticsDenial trends by payer, reason and provider, showing which upstream step needs attention.

Where revenue leaks

The problems we work on

Missing prior authorization
Services performed without a required authorization are one of the most common avoidable denials. We identify the gap and the scheduling step that missed it.
- CARC CO-197Precertification or authorization absent
Medical necessity denials
When the payer says the documentation doesn't support the service, we help organize the clinical record and the payer's coverage policy for your response.
- CARC CO-50Not deemed a medical necessity by the payer
Eligibility and coverage gaps
Terminated coverage or the wrong payer on file leads to denials that can be avoided before the visit. We identify the gap and the eligibility check that would catch it.
- CARC CO-27Expenses incurred after coverage terminated
Timely filing denials
Claims that pass a payer's filing limit are hard to recover. We review the dates and support your response where proof of timely filing exists.
- CARC CO-29The time limit for filing has expired

How it works

Getting started with denial management

Step 1
Denial review
Standard BAA executed prior to system access. We then analyze recent remits and categorize denials by reason code and payer.
Step 2
Review open denials
Open denials are reviewed and prioritized, closest to their deadline first.
Step 3
Categorize new denials
New denials are categorized by reason code as remits come in.
Step 4
Address the cause
Denial trends are reviewed with you, along with the upstream step involved: intake, coding, authorization or charge entry.

Benchmarks

Benchmarks to measure against

Common industry benchmarks and, where noted, our service targets. We can measure your baseline in a free review.

<5%

Denial rate

Common industry target, as a share of claims submitted

≥95%

Clean claim rate

Common industry benchmark for claims accepted on first submission

FAQ

Denial Management & Appeals: common questions

Do you work denials from claims you didn't submit?

Yes. Denial management can run on its own. We review denials from your existing process and show you where they come from.

How do you decide which denials to pursue?

We weigh the dollar value, the reason code and the deadline. Low-value denials with no realistic path are flagged for your decision.

Will you need access to clinical documentation?

For medical necessity and coding questions, yes. Access is read-only and role-based. Standard BAA executed prior to system access.

How quickly will we see a change in our denial rate?

That depends on your payer mix and the causes we find, so we don't promise a specific timeline or result. We show you what is driving your denials and which upstream steps to look at.