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Denials Categories

Each denied claim is assigned to one or more of the following categories automatically when EOB is received:

  1. Authorization Denial: Issues with authorization or pre-approval.
  2. Benefits Denial: Issues related to patient benefits.
  3. Coding Denial: Incorrect or incomplete coding of services.
  4. Coordination of Benefits Denial: Errors related to determining the primary payor.
  5. Demographics Denial: Incorrect patient information.
  6. Diagnosis Denial: Diagnosis code issues.
  7. Duplicate Denial: Duplicate claim submission.
  8. Eligibility Denial: Patient not eligible for services on the date of service.
  9. Fee Schedule Denial: Discrepancy between billed amount and payor’s fee schedule.
  10. Missing or Invalid Data Denial: Missing or incomplete information.
  11. Medical Necessity Denial: Service deemed not medically necessary.
  12. Payer Guidelines Denial: Non-compliance with payor-specific policies.
  13. Timely Filing Denial: Claims submitted after the payor’s deadline.
  14. Other Denials: Miscellaneous denials that do not fall into the above categories.

Each denial category has specific codes associated with it, which are pulled from the EDI 835 files or manual payment postings. 

Changing the Denial Category

In the Collections Module, users can manually change the denial category for a specific claim. To do this, follow these steps:

  • Navigate to the Collections Module: Access the invoice in question by locating it on the Collections Page.
  • Change Denial Category: In the denial column, you will see a Dropdown Menu that allows you to select the appropriate denial category. This dropdown will have all denial types listed, and the default option is 'Not Applicable'. Simply selecting a new denial category from the dropdown will automatically update the invoice's denial status and assign it to the correct category.
  • Auto-Save: Once you select the new denial category, it is saved automatically without the need for an additional confirmation step.

Managing Denial Workflows

  • Each denial can have multiple workflows active at once, depending on the type of denial. The module provides tools for managing these workflows, including assigning tasks to different team members and tracking their progress.

Assigning Denials:

  • Users can assign denial workflows to team members using the Assigned To dropdown. Multiple workflows can be active at the same time, and users can see who is responsible for each step of the denial resolution process.

Documenting Workflow Progress:

  • Each workflow allows users to add notes and attach relevant documentation (such as corrected EOBs or claim forms). This documentation is crucial for maintaining an audit trail of all denial management actions.

 

Denials Resubmission

  • Once the denial reason has been resolved, and the necessary corrections have been made (such as updating the patient’s coverage information or correcting a diagnosis code), the claim can be resubmitted to the payor. The resubmission process is initiated directly from the Denials Page by clicking on the ‘Resubmit’ button. 

Closing Denials

  • Once a denial is fully resolved and the claim has been resubmitted, the claim is automatically removed from the Denials Management Module. The resubmitted claim will now appear on the Posted Invoices page and will be reflected in all relevant reports.
  • To help users easily identify resubmitted claims, the system appends "RE" to the invoice number. Additionally, in reports, you will see both the resubmitted invoice and the original source invoice, providing clear traceability of the entire process.

Ideal Workflow for Denials Management

The ideal workflow in the Denials Management Module involves a collaborative process where tasks are efficiently assigned and executed. When you access the Denials page, follow these steps:

  • View Assigned Tasks: Upon entering the Denials page, you will see the tasks assigned to you. These tasks represent your role in addressing the denial. Each task is part of a workflow step in the overall denial resolution process.
  • Execute Assigned Tasks: Complete the task assigned to you by investigating, correcting the necessary data, and resolving the issue at hand. After executing your task, move the workflow forward by assigning it to the next responsible team member or department.
  • Assign to Next Person: Once your part of the workflow is complete, assign the workflow to the next responsible person for their action. This ensures the workflow progresses smoothly through the required steps.
  • Manager Oversight: Managers can monitor the Denials page to see all open workflows and the current step each workflow is in, ensuring visibility and accountability across the team.
  • Workflow Resolution: Once all steps in the workflow are completed and the denial is resolved, resubmit the corrected claim for processing.
  • Closing the Workflow: After the claim has been resubmitted, mark the workflow as Resolved, and then close the workflow. This removes it from the active workflow list while retaining all historical data in the timeline for future reference.