Every Denied Claim Is Earned Revenue. We Go Get It Back.
Most practices don’t lose money to denials because the payer was right — they lose it because nobody had time to work the denial before the appeal window closed. MedVersify works every denial by reason code, fixes what caused it, appeals what deserves appealing, and clears the aged A/R your last billing team left behind.
- Every denial worked by CARC/RARC reason code
- Corrected claims and appeals at every level
- Old A/R cleanup — 90, 120, 365+ day buckets
- Timely-filing deadlines tracked per payer
- No denial written off without a documented review
- Monthly root-cause report your front desk can act on
The Revenue Lost to Denials Is Mostly Revenue Nobody Chased
41%
Of Providers Say 10%+ of Claims Are Denied
Two in five providers now report that at least one in ten claims is denied — double the 5% that well-run revenue cycles target.
Experian Health, State of Claims 2025
$43.84
Average Cost to Fight One Denial
Providers spent about $43.84 in administrative cost per appealed claim with private payers — and more than 54% of initially denied claims were ultimately paid.
Premier Inc. survey of 2022 claims, 2024
80.7%
Of Appealed MA Prior-Auth Denials Overturned
When Medicare Advantage prior authorization denials were actually appealed in 2024, insurers reversed four out of five of them in whole or in part.
KFF analysis of CMS data, 2026
11.5%
Of Those Denials Were Appealed at All
The overturn rate is high; the appeal rate is tiny. That gap is where a denial management team earns its fee.
KFF analysis of CMS data, 2026
Denial Management That Works Both Ends: Recovery and Prevention
Denial management is part of our full medical billing and revenue cycle service, and it is also available on its own for practices that keep their billing in-house but can’t keep up with the denial queue or an aging A/R backlog.
Denial triage by dollar value and deadline
Every denial is logged the day the ERA posts, sorted by appeal deadline and dollar value, so high-value claims close to their filing limit are worked first — not whatever happens to be on top of the pile.
Root-cause coding with CARC and RARC
We read the claim adjustment reason code and the remark code together. CO-16 with an N-series remark is a different fix from CO-16 on its own — reading both is the difference between a one-day correction and a resubmission that denies again.
Corrected and replacement claims
Front-end errors — wrong member ID, missing modifier, diagnosis pointer, or rendering NPI — are fixed and sent as a corrected claim (frequency code 7) instead of a duplicate that triggers a CO-18.
Written appeals with the right evidence
Medical-necessity and coding denials get a written appeal with the clinical documentation, the payer’s own policy language, and — where it applies — the coverage rule the payer has to answer to.
Old A/R cleanup
Inherited a backlog from a previous biller? We work aged claims bucket by bucket (91–120, 121–180, 181–365, 365+), check each against its payer’s timely-filing limit first, and recover what is still recoverable.
Underpayment and downcoding review
Not every lost dollar shows up as a denial. We compare paid amounts with your contracted rates and billed E/M levels with paid levels, which is how payer downcoding gets caught.
Prevention feedback to your front desk
Each month you get the top denial reasons by payer and by cause — eligibility, authorization, coding, documentation — with the specific process change that stops each one from recurring.
Prior authorization follow-through
Authorization denials (CO-197, CO-15) are the fastest-growing category. We pair denial work with prior authorization management so the same request isn’t denied twice.
Patient-responsibility clean-up
PR-1, PR-2 and PR-3 adjustments are not denials — they are balances to bill the patient. We separate them out so your denial rate reflects real denials and patient statements go out on time.
The Denial Codes We See Most — and How Each One Gets Fixed
Claim adjustment reason codes (CARCs) are maintained by the X12 standards body and appear on every electronic remittance. The group code in front tells you who owns the balance: CO (contractual — the practice can’t bill the patient), PR (patient responsibility), or OA (other adjustment). Use our denial rate calculator to see where your own rate sits.
Common CARC denial codes
| Code | What it means | Usual cause | How it gets worked |
|---|---|---|---|
| CO-4 | Procedure code is inconsistent with the modifier, or a required modifier is missing | Missing 25, 59/X{EPSU}, or laterality modifier | Correct the modifier and send a corrected claim |
| CO-11 | Diagnosis is inconsistent with the procedure | Wrong diagnosis pointer or a code that does not support necessity | Re-link diagnoses from the note; corrected claim |
| CO-16 | Claim lacks information or has a submission/billing error | Missing NPI, referring provider, or data named in the RARC | Read the RARC, add the missing data, resubmit |
| CO-18 | Exact duplicate claim or service | A resubmission sent as a new claim instead of a corrected one | Check the original status; send frequency code 7 if a change was needed |
| CO-22 | Care may be covered by another payer (coordination of benefits) | Patient has primary coverage elsewhere or COB not updated | Verify COB with the patient and payer; bill the primary first |
| CO-27 | Expenses incurred after coverage terminated | Eligibility not re-verified at the visit | Find active coverage; bill the patient if none existed |
| CO-29 | Time limit for filing has expired | Claim submitted after the payer’s timely-filing limit | Appeal only with proof of timely original submission |
| CO-50 | Non-covered — not deemed medically necessary | Documentation or diagnosis does not meet the payer policy or LCD | Written appeal with records and the policy criteria |
| CO-97 | Payment included in the allowance for another service | NCCI bundling edit | Review whether a distinct-service modifier is supported; appeal or accept |
| CO-197 | Precertification/authorization absent | Service required prior authorization that wasn’t obtained | Request retro-authorization where allowed; appeal with urgency notes |
Code descriptions are paraphrased. The X12 CARC and RARC lists are updated several times a year — we work from the current published list, not a printed cheat sheet.
The five levels of a Medicare Part A/B appeal
Traditional Medicare has a fixed appeal ladder with fixed deadlines. Commercial and Medicare Advantage plans set their own timelines in the provider contract — we track both.
| Level | Who decides | Deadline to file | Notes |
|---|---|---|---|
| 1. Redetermination | Your Medicare Administrative Contractor (MAC) | 120 days from the initial determination | Most denials should be won or fixed here |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | 180 days from the redetermination | Submit all evidence now — later levels may limit new evidence |
| 3. Hearing | Administrative Law Judge (OMHA) | 60 days from the reconsideration | Requires a minimum amount in controversy, adjusted every year |
| 4. Council review | Medicare Appeals Council | 60 days from the ALJ decision | Review of the hearing decision |
| 5. Judicial review | Federal district court | 60 days from the Council decision | Higher amount-in-controversy threshold applies |
Simple clerical errors on Medicare claims can often be fixed through a reopening instead of a formal appeal, which is faster. Source: CMS Medicare Parts A & B appeals process.
Six Denial Habits That Quietly Cost Practices Money
Resubmitting instead of correcting
Sending the same claim again as a new claim usually earns a CO-18 duplicate denial, which pushes the claim even closer to its filing limit. A changed claim should go out as a corrected claim.
Writing off small balances by default
A $40 denial repeated across 300 visits a year is $12,000. Small denials with the same root cause are the cheapest money to recover, because one fix clears every one of them.
Counting patient responsibility as denials
PR adjustments inflate the denial rate and hide the real problems. Separating PR from CO is the first step to a denial rate you can actually manage.
Appealing without the payer’s own policy
A medical-necessity appeal is strongest when it quotes the payer’s coverage policy or the Medicare LCD and shows, line by line, how the record meets it.
Losing track of timely filing
Medicare allows 12 months from the date of service to file a claim; many commercial contracts allow far less. Once the filing limit passes, a fixable denial becomes a write-off.
Never sending the lesson upstream
Most denials start at registration, eligibility, or authorization. If the denial team never reports back to the front desk, the same denial comes back next month.
How MedVersify Works Your Denials
Free denial & A/R assessment
We pull your last 90 days of remittances and your current A/R aging to size the problem by payer, reason code, and dollar value.
Triage by deadline and value
Claims closest to their appeal or filing limit, and with the most money at stake, go to the front of the queue.
Correct, resubmit, or appeal
Each denial gets the right fix: a corrected claim, a reopening, a phone call to the payer, or a written appeal with evidence.
Follow up until it closes
Every open item has an owner and a next-touch date. Nothing sits in “pending” without someone checking it.
Feed prevention upstream
Root causes go back to registration, coding, and authorization as specific process changes, not a generic “be more careful.”
Report every month
Denial rate, recovery dollars, A/R over 90 days, and the top five causes by payer — in a report you can read in five minutes.
Frequently Asked Questions
What is denial management in medical billing?
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What is a good claim denial rate?
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Can you recover old A/R from a previous billing company?
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How long do I have to appeal a Medicare denial?
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Is it worth appealing prior authorization denials?
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Do you offer denial management without taking over all of our billing?
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How is denial management priced?
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What is the difference between a rejection and a denial?
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Free Denial & A/R Review
Find Out How Much of Your A/R Is Still Recoverable.
Send us your details and we’ll review your recent denials and aging report. You’ll get a straight answer on what can still be collected — whether or not you work with us.
Prefer to call? (507) 312-9282Sources
- KFF — Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024
- CMS — Medicare Parts A & B appeals process
- X12 — Claim Adjustment Reason Codes (CARC)
- X12 — Remittance Advice Remark Codes (RARC)
- Experian Health — State of Claims 2025
- Premier — Private payers retain profits by refusing or delaying legitimate medical claims
- HFMA — 7 KPIs providers should be tracking
Payer rules change often. Figures and deadlines on this page reflect the sources above as of the date they were published — confirm against your payer contract and current CMS guidance before relying on them for a specific claim.