Denial management services
Denials worked to resolution, appeals filed within payer deadlines, and the cause addressed to help keep the same denial from coming back.
A denial is the payer telling you exactly what went wrong, in code. CO-16 means information is missing. CO-197 means there was no authorization. CO-97 means the service was bundled into something else. Practices that only resubmit denials one at a time keep getting the same ones, because the front desk, coding or documentation error that caused them never changes.
SFA Solutions reads the CARC and RARC codes on each ERA, sorts each denial by cause, and takes the right action: corrected claim, reopening, written appeal with records, or a call to the payer. We track appeal deadlines by payer, including Medicare's 120-day window for redeterminations. Each month we report denials by code, payer and cause, and we fix the source with your team, whether that is an eligibility step, a missing modifier or a documentation gap. For our clients, first-pass denials are targeted under 5%.
Who this is for
Denial management helps any practice with a denial rate above 5%, practices with a large stack of unworked denials, and specialties with heavy authorization or bundling rules such as radiology, cardiology, gastroenterology, orthopedics, physical therapy and behavioral health. It is included in our full RCM package and available on its own.
Related services
What our denial management service covers
Daily denial review
ERAs reviewed the day they post, with each denied line tagged by CARC, RARC, payer, provider and cause.
Corrected claims and reopenings
Fixable errors resubmitted with the right claim frequency code, or handled through a Medicare reopening for clerical errors.
Written appeals
Appeals with medical records, payer policy citations and NCCI or LCD references for medical necessity and bundling denials.
Deadline tracking
Appeal windows logged for each denial, including Medicare redetermination (120 days) and reconsideration (180 days) limits.
Root-cause fixes
Denial patterns traced back to intake, eligibility, coding or documentation, with specific changes agreed with your staff.
Denial reporting
Monthly denial rate, top codes, top payers, dollars recovered and dollars at risk, by provider and location.
How we deliver it
Days 1 to 5
We pull your open denials, sort them by deadline and value, and start with anything close to an appeal limit.
Weeks 1 to 4
Corrected claims and appeals go out in batches by payer, with reference numbers recorded on each account.
Month 1 review
We show you your top denial codes and their causes, and agree on the front-end and coding changes that prevent them.
Ongoing
Daily denial work, monthly trend reporting, and claim review rules updated when a payer starts denying something new.
Common denial codes and the usual fix
| Code | What it means | Usual fix |
|---|---|---|
| CO-16 | Claim lacks information or has submission or billing errors (check the RARC for what is missing) | Correct the missing or invalid data and resubmit |
| CO-97 | Payment is included in another service already adjudicated (bundling) | Check NCCI edits; append 25, 59 or an X modifier only if documentation supports a distinct service, or appeal |
| CO-50 | Not a covered service because the payer does not deem it medically necessary | Review the LCD or payer policy, confirm diagnosis coding, appeal with records |
| CO-197 | Precertification, authorization or notification absent | Request retro authorization if the payer allows it, appeal, and fix the auth workflow |
| CO-29 | Time limit for filing has expired | Appeal with proof of timely filing such as clearinghouse acceptance reports |
| PR-1 | Deductible amount (patient responsibility) | Not an error: bill the patient, and collect estimates at check-in going forward |
Denial Management for your specialty
We bill for 28+ specialties. These are the ones we work with most.
Nurse Practitioner billing
Billing for NP-led and physician-NP practices, from the 85% Medicare rate and incident-to rules to split/shared visits and getting each NP credentialed under the right NPI.
Learn moreInternal Medicine billing
Billing for internists who manage complex, chronic patients, with E/M levels, wellness visits and care management codes captured when the documentation supports them.
Learn moreOphthalmology billing
Eye exam codes, refraction, diagnostic testing, cataract globals and high-cost injectable drugs all follow their own rules. Ophthalmology is one of the specialties we bill most often.
Learn moreQuestions about denial management
What is a normal denial rate?
Many practices see 5% to 10% of claims denied on first submission. A well-run practice aims for under 5%. Many denials can be prevented at eligibility, coding and claim review, which is where most of our denial work starts.
What do CO, PR and OA mean in front of a denial code?
They are group codes. CO (contractual obligation) means the amount is the provider's responsibility and cannot be billed to the patient. PR (patient responsibility) means the patient can be billed, such as PR-1 for deductible or PR-2 for coinsurance. OA (other adjustment) covers adjustments that fit neither group.
How long do we have to appeal a Medicare denial?
A Medicare redetermination must be requested within 120 days of receiving the initial determination. If that is denied, the next level, reconsideration by a Qualified Independent Contractor, must be requested within 180 days. Simple clerical errors can often be fixed through a reopening instead of an appeal.
Is CO-45 a denial?
No. CO-45 means the charge exceeds the fee schedule or maximum allowable, and the difference is a contractual write-off. We still check that the allowed amount matches your contract, because a wrong allowed amount is an underpayment.
How long do commercial payers give for appeals?
It depends on the plan and your contract. Windows of 60 to 180 days from the denial date are common. We record each payer's limit on each denial so appeals go out on time.
Start with a free review
Tell us a little about your practice. We will look at where denial management is costing you money today and walk you through what we find.
- No commitment
- Reply from an RCM specialist, typically within one business day
- No patient records needed to start
Get a free review
An RCM specialist typically replies within one business day.