Stage Denial Recovery Process
HIPAA-Compliant Process
Years in U.S. Medical Billing
Most practices work the easy half of a denial — resubmit and hope. We do the whole job: root-cause diagnosis, appeals built to win, and front-end fixes that stop the same denial from coming back next month.
The scale of the problem
The real cost of an unworked denial
Denial rates have climbed for four straight years — but most denied revenue is recoverable, not lost.
Of Providers See 10%+ Denial Rates
Up 11 pts since 2022 — Experian Health, 2025.
Of Claims Denied on First Submission
To private payers — Premier Inc. survey.
Of Worked Denials Get Overturned
54.3% for private payers — Premier Inc. survey.
Avg. Cost to Fight One Denial
Up from $43.84 the year prior — Premier Inc.
The constraint on denial revenue is almost never whether a claim is winnable. It's whether anyone has the time, the process, and the payer knowledge to work it before the filing window closes.
How it works
What denial management actually involves
Resubmitting a claim without diagnosing it produces a second denial and burns a filing window. Our process runs in six stages.
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01
Capture & Categorize
Every denial is pulled from the 835 remittance, EOBs, and payer portals, then sorted by CARC/RARC code, payer, provider, and dollar value.
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02
Root-Cause Analysis
We separate the stated reason from the actual reason — the CARC tells you the category, the RARC tells you what's actually missing.
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03
Triage by Value
Each denial is scored by recovery value, appeal strength, and filing window remaining — so time goes where it pays off.
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04
Correct or Appeal
Correctable claims go back with the proper resubmission code. Substantive denials get a formal appeal with an evidence packet.
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05
Track to Resolution
Every appeal is tracked with follow-up cadence and escalation triggers until it pays, is overturned, or exhausts the ladder.
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06
Feed the Fix Upstream
Recurring patterns are traced to their origin — front desk, coding, credentialing — and returned to your team as a specific fix.
A distinction that matters
Rejection or denial? They're not the same thing
Getting this right determines your entire response — get it wrong and you waste the filing window.
Rejection
Caught by the clearinghouse or payer front-end before it ever reaches adjudication — invalid member ID, missing NPI, a format error. No appeal rights exist, because nothing was ever reviewed. We fix the error and submit it as a new claim.
Denial
Reviewed and declined by the payer after adjudication — medical necessity, missing authorization, bundling, timely filing. It carries a CARC code and real appeal rights. We either correct and resubmit it, or file a formal appeal.
Code-level competence
The denials we work most
Nearly every code below traces back to something that happened before the claim went out.
Claim Lacks Information
Missing RARC-specified data or an invalid modifier. We read the RARC, correct the specific element, and resubmit as a corrected claim.
Authorization Absent
Auth was never obtained, the wrong CPT was authorized, or it expired. We request a retro-auth where allowed, or appeal with medical necessity documentation.
Not Medically Necessary
The diagnosis doesn't support the procedure per LCD/NCD on file. We appeal with clinical notes and the applicable policy cited directly.
Timely Filing Expired
The claim was held internally or sent to the wrong payer first. We appeal with proof of timely submission — clearinghouse reports, the original ICN.
Bundled Into Another Service
An NCCI bundling edit, or a missing modifier 25, 59, or XE/XS/XP/XU. We review the modifiers and appeal where a separate service is documented.
Not Covered Under the Plan
A benefit exclusion, an eligibility lapse, or the wrong plan verified up front. We re-verify eligibility, or appeal if the benefit was in fact active.
What we see in practice AR
Where practices lose denial revenue
Four predictable places, in our experience reviewing practice AR.
Nobody Owns the Queue
Denials get worked only when someone has spare capacity — in a busy practice, that's never. Claims age past the filing window.
Low-Dollar Denials Abandoned
A $90 denial isn't worth an hour of staff time — so it's written off. Two hundred of those a year is $18,000 surrendered.
Resubmitted, Not Diagnosed
The claim goes back unchanged, gets denied again — often as a duplicate — shortening the window and muddying the appeal record.
Appeals Filed, Never Tracked
No follow-up cadence, no escalation, no confirmation of receipt. Payers are not obligated to remind you it's pending.
Diagnosis before action
Every denial is read, not just resubmitted
A CO-16 denial on its own tells you almost nothing — the accompanying RARC tells you what's actually missing. Blind resubmission produces a second denial and burns a filing window. We read the code, confirm the real cause, and only then decide whether it's a corrected claim or a formal appeal.
Talk to a specialistAppeal mechanics
The appeals process, explained properly
Appeal rights and deadlines vary by payer type, and missing a window is unrecoverable.
Redetermination
Level one, filed with the Medicare Administrative Contractor — generally within 120 days of the initial determination.
Reconsideration
Level two, filed with a Qualified Independent Contractor — generally within 180 days of the redetermination notice.
ALJ Hearing
Level three — generally within 60 days, subject to an amount-in-controversy threshold CMS updates annually.
Council & Judicial Review
Levels four and five — Medicare Appeals Council, then federal district court, subject to a higher threshold.
MA & Commercial Appeals
Their own internal levels, then external independent review — commonly 90 to 180 days, but always contract-specific. We verify the actual policy before filing.
What Wins an Appeal
The specific denial code and argument, clinical documentation, the LCD/NCD cited directly, and proof of authorization or timely filing — not a form letter.
Why practices choose us
What makes HS Med Solutions different
The Whole Denial, Low-Dollar Included
Recovery and prevention are one engagement, not an upsell — including the small denials practices usually abandon.
You See the Same Data We See
Denial rate by payer, provider, and reason, with recovery status on every claim — not a quarterly PDF.
We Overlay, Not Just Replace
If your billing team is performing well on submission but underwater on denials, we take just that workstream. Not every practice needs to switch vendors.
We Work Your Actual Payer Mix
Denial behavior differs sharply between Medicare, Medicare Advantage, Medicaid MCOs, and commercial plans. Each gets the right documentation and escalation path.
Getting started
What the first 90 days look like
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Days 1–15
Diagnosis
We audit your denial history and AR aging, categorize by code, payer, and provider, and identify claims still inside their filing window. You get a written finding of recoverable dollars before any commitment.
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Days 16–45
Recovery
Work begins on the highest-value recoverable denials first, prioritizing claims nearest their deadline. Corrected claims and appeals go out in volume.
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Days 46–90
Prevention
Root causes are traced upstream and returned to your team as specific workflow corrections. Denial rate reporting becomes a standing metric. Recovery continues in parallel.
Cash flow impact typically becomes visible in month two, because the first payer response cycle on corrected claims and appeals runs 30 to 45 days. Any vendor promising results faster than the payers themselves move is selling you something.
Not a form letter
Appeals built on evidence, not templates
Most unsuccessful appeals fail not because the claim was unwinnable, but because the appeal was a form letter attached to a claim copy. Payers aren't required to construct your argument for you — every appeal we file cites the specific denial code, the applicable LCD or NCD, and the clinical documentation that supports what was actually billed.
See how it works
The practical details
Pricing and compliance
Percentage of Collections
We're paid when you're paid. Aligns our work directly with the revenue we actually recover for you.
Flat Monthly Fee
A predictable, fixed cost where denial volume is steady enough to price that way.
HIPAA-Compliant, BAA-Covered
A signed Business Associate Agreement with every client, role-based access controls, and encrypted transmission and storage.
The audit is free and carries no obligation. If we review your denial history and conclude there isn't enough recoverable revenue to justify the engagement, we'll tell you that.
Questions, answered
Denial management, answered
What practice owners ask most before handing off denial work.
What is denial management in medical billing?
Denial management is the process of identifying why insurance claims were denied, correcting or appealing them to recover payment, and fixing the underlying causes so the same denials stop recurring. It covers both recovery of denied revenue and prevention of future denials.
What is a good claim denial rate?
HFMA considers 5-10% an acceptable range, with under 5% representing strong performance. Experian Health's 2025 State of Claims survey found 41% of providers now exceed a 10% denial rate, up 11 percentage points since the survey began in 2022 — which generally points to a problem in eligibility, authorization, coding, or documentation rather than payer behavior alone.
What is the difference between a claim rejection and a claim denial?
A rejection happens before adjudication — the clearinghouse or payer front-end catches an error and the claim never enters processing, so there is nothing to appeal. A denial happens after adjudication: the payer reviewed the claim and declined to pay, which carries a CARC code and appeal rights. Rejections are corrected and resubmitted as new claims; denials are corrected or formally appealed.
How long do I have to appeal a denied claim?
It depends on the payer. Medicare fee-for-service allows 120 days from the initial determination to request a redetermination. Commercial payers commonly allow 90 to 180 days, but the window is contract-specific and must be verified against the individual payer's policy. Missing the deadline is the one denial failure that cannot be recovered.
What percentage of denied claims can be recovered?
Premier Inc.'s national provider survey found just over half of denied claims — 51.7% overall, and 54.3% for private payers specifically — are ultimately overturned and paid when properly worked. Actual recovery depends on the denial reason, documentation quality, and how much of the filing window remains when the claim is worked.
Do I have to switch my entire billing to use your denial management services?
No. Denial management can be engaged as a standalone workstream alongside your existing billing team or vendor. If your submission process is working and only denials and AR are underwater, replacing everything is unnecessary.
Stop writing off revenue you already earned.
Get your free denial audit.
Send us your denial history and we'll tell you — specifically, in dollars — what's still recoverable and what's causing it.
No obligation. If there isn't enough recoverable revenue to justify working together, we'll tell you.