Denials Management Process

Denials Management Process

As part of our provider solution, our clinical specialists review claims along with medical records for medical necessity. We identify the services rendered and validate that the appropriate levels of care are billed correctly, addressing issues regarding documentation, lack of medical necessity and plan of care. We manage every step of the clinical appeals process through:

  • Review and analysis of denials

  • Writing professional appeal letters

  • Quality assurance review

  • Submission

  • Follow-ups

Clinical Appeals Management

Our team of registered nurses ensures all written orders are validated for accurate levels of care and treatments, helping your healthcare facility adhere to industry standards and regulatory requirements.

We manage every step of the appeals process to recover revenue lost to inappropriate denials.

Clinical Appeals Management is a critical component of hospital revenue integrity strategy. We assist you by ensuring you receive accurate reimbursement for the services you provide through the identification, management and education required to improve claims recovery efforts.

Focus Areas

  • Medical/Surgical

  • Newborn Nursery

  • NICU levels I-IV

  • Oncology

  • Outpatient surgeries/procedures

  • Pediatrics

  • PICU

  • RAC

  • Rehabilitation

  • Telemetry

  • Trauma

  • Hospice

  • Chemotherapy infusion services per

  • NCD/LCD criteria

  • CMS Inpatient only services/procedures

  • DRG/APR disputes

  • ICU

  • Inpatient level of care downgraded to

  • Observation status

  • Labor & Delivery

  • Level of Care & Severity of Illness

  • Medical Necessity

Our Approach

When it comes to the appeals management of clinical denials, knowledge is key to resolving and overturning claim denials. Our clinical appeals team of Registered Nurses (RNs) and Compliance specialists are employed on-shore, and have an average of over 10+ years of experience. They hold multiple of the following credentials: RN, CCS, CDI, LNCC, C-DAM, CCS-P, CDIP, CCDS, RHIA, RHIT and various audit and compliance credentials.