Denial Management Services That Turn Denied Claims Into Paid Claims
Every denial worked, every deadline met, every root cause fixed.
Denied claims are revenue you've already earned, sitting in a queue. Our California denial management team works every denial within 48 hours of the remittance, corrects or appeals it before the payer's deadline, and traces each one back to the coding, front-desk or payer issue that caused it, so the same denial doesn't come back next month.
- Every denial touched within 48 hours
- Appeals built to each payer's rules
- Medi-Cal, Medicare, commercial and IPA disputes
- HIPAA compliant with signed BAA
What Are Claim Denial Management Services?
Denial management is the part of the revenue cycle that recovers payment on claims a payer has refused, and stops the same refusals from happening again. Claim denial management services cover the full loop: reading the 835 remittance, classifying each denial by its CARC and RARC codes, correcting and resubmitting what can be fixed, appealing what was wrongly denied, and feeding every root cause back to the people who can prevent it.
Denial vs Rejection: Why the Difference Matters
Happens before the payer accepts the claim, usually at the clearinghouse or payer front end, because of a formatting or data error. It never entered adjudication, so you fix it and resubmit.
Comes after the payer processed the claim and refused to pay all or part of it. It needs a corrected claim, a reconsideration or a formal appeal, each with its own deadline.
Treating a denial like a rejection is how money ages out.
Denial Management Services Built Around Recovery and Prevention
Working denials recovers this month's revenue. Fixing their causes protects every month after. We do both.
Denial Capture and Triage
Every 835 remittance is read the day it posts. Denials are split into full-claim and line-item denials, mapped by CARC and RARC code, and prioritized by dollar value and appeal deadline.
Corrected Claims and Resubmissions
Fixable errors are corrected and resubmitted with the right claim frequency code, so the payer reprocesses instead of rejecting a duplicate.
Coding Denial Management
Certified coders work denials tied to codes: diagnosis that doesn't support medical necessity, NCCI bundling, modifier 25 and 59 conflicts, MUE unit limits, and E/M level disputes. Each fix is documented and shared with the provider or coder who made the original code choice.
Appeals and Provider Disputes
Written appeals with medical records, payer policy citations and letters of medical necessity. In California, we file formal provider disputes with health plans and IPAs, and escalate when a plan misses its own deadlines.
Underpayment and Contract Variance Recovery
We compare every payment to your contracted fee schedule and dispute short pays, incorrect multiple-procedure reductions and wrong fee schedule versions.
AR Follow-Up for Denied and Unpaid Claims
Denials and no-response claims are worked together. We call payers on claims with no response at 30 days, chase 90+ day balances and document every contact.
Aged Denial and Backlog Clean-Up
Project-based recovery of old denials and AR over 90, 120 and 180 days, worked by deadline and recoverable value.
Root Cause Analysis and Prevention
Monthly reports by payer, provider, CPT code and denial reason, with a fix owner and due date for each top issue: front desk, authorization, coding, credentialing or charge entry.
Recoupments and Payer Audits
We review takebacks, overpayment demands and records requests, and respond or dispute within the window.
The Claim Denials We Resolve, and How We Fix Each One
A denial code tells you what went wrong. Knowing the fix is what gets you paid.
Eligibility and coverage CO-27, CO-31, CO-109, CO-22
- What it means
- Coverage ended, patient not found, wrong payer, or another plan is primary
- How we resolve it
- Find active coverage, rebill the right payer, correct coordination of benefits
- Prevention owner
- Front desk / eligibility
Authorization and referral CO-197, CO-198, CO-15
- What it means
- No authorization, auth exceeded, or invalid auth number
- How we resolve it
- Retro authorization where allowed, appeal with clinical urgency, correct auth number
- Prevention owner
- Prior authorization team
Coding and medical necessity CO-11, CO-50, CO-167, CO-4
- What it means
- Diagnosis doesn't support the procedure, or modifier is wrong
- How we resolve it
- Coder review, corrected claim or appeal with records and payer policy
- Prevention owner
- Coders and providers
Bundling and units CO-97, CO-151, CO-119
- What it means
- Service is bundled under NCCI, frequency exceeded or benefit maximum reached
- How we resolve it
- Modifier correction where documentation supports it, or appeal
- Prevention owner
- Coders
Missing or invalid information CO-16 (with RARC detail)
- What it means
- Claim lacks required data, such as NPI, referring provider or NDC
- How we resolve it
- Add the missing element and resubmit as a corrected claim
- Prevention owner
- Charge entry
Duplicate CO-18
- What it means
- Payer thinks the claim was already billed
- How we resolve it
- Prove it's a distinct service, or confirm the original is paid
- Prevention owner
- Billing
Timely filing CO-29
- What it means
- Claim filed after the payer's deadline
- How we resolve it
- Appeal with proof of timely submission (clearinghouse reports, 277CA)
- Prevention owner
- Billing
Provider enrollment CO-B7, CO-170
- What it means
- Provider not enrolled or not credentialed for the date of service
- How we resolve it
- Fix enrollment, request retro effective date, rebill
- Prevention owner
- Credentialing
Non-covered services CO-96, CO-204
- What it means
- Benefit excluded under the patient's plan
- How we resolve it
- Check for waiver or ABN, bill patient correctly, or appeal coverage
- Prevention owner
- Front desk
Underpayment CO-45 (misapplied), CO-59
- What it means
- Paid below contract or wrong multiple-procedure reduction
- How we resolve it
- Contract variance dispute
- Prevention owner
- Billing / contracting
Denial types we classify: hard vs soft denials, clinical vs administrative denials, front-end vs back-end denials, full-claim vs line-item denials.
Denial Management Services in California: Deadlines That Work in Your Favor
California gives providers stronger dispute rights than most states. Most practices never use them. We do, on every eligible claim.
Provider Disputes With Health Plans and IPAs
Under California's claims settlement rules (28 CCR 1300.71.38), every DMHC-regulated health plan and every capitated IPA or medical group that pays claims must run a fast, fair dispute process:
- 1Provider files a disputeWithin 365 days of the plan's action on the claim
- 2Plan acknowledges the dispute2 working days (electronic) or 15 working days (paper)
- 3Plan issues a written decision45 working days from receipt
- 4Plan pays if the provider winsWithin 5 working days of the decision, with interest
- 5Returned for missing informationProvider has 30 working days to submit an amended dispute
When an IPA or medical group denies a dispute involving medical necessity or utilization review, the provider has an unconditional right to appeal to the health plan itself for a fresh review. We use that right instead of accepting the IPA's answer as final.
Medicare's Five Appeal Levels
Medicare Part B claims in California move through five appeal levels, each with its own decision-maker and filing window:
- 1120 days from the initial determinationRedeterminationNoridian (Medicare contractor for California)
- 2180 days from the redeterminationReconsiderationQualified Independent Contractor (QIC)
- 360 daysHearingAdministrative Law Judge (ALJ)
- 460 daysReviewMedicare Appeals Council
- 560 daysJudicial reviewFederal district court
Late Payment and Interest (AB 3275)
For DMHC-regulated plans, AB 3275 requires payment of complete claims within 30 calendar days, with interest at 15% per year after that. We track every late payment and claim the interest and penalties owed.
Regulators Are Enforcing These Rules
The DMHC has fined plans for missing dispute deadlines, including a $450,000 penalty against Health Net in February 2026 and corrective action against Anthem Blue Cross plans in 2024 for tens of thousands of late disputes. When a plan misses its clock, we document it and escalate.
Medi-Cal Denials
For fee-for-service Medi-Cal, we use Claims Inquiry Forms to correct and trace claims, and file formal appeals within 90 days of the action on the Remittance Advice. Medi-Cal managed care denials go through each plan's provider dispute process, such as L.A. Care, IEHP, CalOptima Health, Health Net and Molina.
Sources: 28 CCR 1300.71.38 · 28 CCR 1300.71 · DMHC APL 25-007 on AB 3275 · Davis Wright Tremaine on DMHC enforcement · DMHC press release, 2024
How Denial Management Works in Our Revenue Cycle
Seven steps in a continuous loop — Prevent feeds straight back into Capture.
Turnaround commitments
- Every denial touched within 48 hours of the remittance
- Corrected claims out within 3 business days
- Appeals filed well inside the payer's window
- Monthly root-cause report with action items
- 1
Capture
835 remittances and clearinghouse reports are read daily, and every denial and rejection is logged with its CARC, RARC, dollar value and deadline.
- 2
Triage
Denials are sorted by recoverability, dollar value and days left to act, so the highest-value, closest-deadline claims are worked first.
- 3
Investigate
A specialist reviews the claim, chart, eligibility, authorization and contract to find the actual cause, not just the code.
- 4
Resolve
Corrected claim, reconsideration, provider dispute, appeal or peer-to-peer, whichever path the payer and the denial call for.
- 5
Follow up
Every open appeal and dispute is tracked against the payer's own deadline and escalated when it's missed.
- 6
Post and reconcile
Recovered payments are posted and checked against the contracted rate.
- 7
Prevent
Each month, the top denial causes get a named fix owner: front desk, authorization, coding, credentialing or charge entry. We measure whether the fix worked — and the loop starts again at Capture.
The Metrics We Report Every Month
Why Outsource Denial Management Services?
In most practices, denials are worked when someone has time, which means the easy ones get fixed and the valuable ones age out. When you outsource denial management services, every denial has an owner, a deadline and a documented outcome.
More revenue recovered
Denials are worked by value and deadline, not by whoever opens the remittance first.
Fewer denials next month
Root-cause fixes reach the people who can stop them, and we measure whether they did.
Lower AR and faster cash
Denied and unpaid claims are worked together, so balances stop sliding past 90 days.
Specialist skill on every claim
Certified coders on coding denials, appeal writers on clinical denials, AR specialists on payer follow-up.
No hiring or turnover risk
Coverage continues through vacations, resignations and volume spikes.
Full visibility
Monthly reporting shows exactly what was recovered, what was written off and why.
Healthcare Denial Management Services for Every Setting
Physician Denial Management Services
Solo and group practices across primary care and specialties, with coding and AR support in one team.
Hospital Denial Management Services
Outpatient, emergency and professional fee denials, clinical and DRG-related appeals, and underpayment recovery against hospital contracts.
Ambulatory Surgery Centers
Implant, multiple-procedure and authorization denials.
FQHCs and Community Clinics
Medi-Cal managed care disputes, PPS claim issues and wrap-around payment follow-up.
Behavioral Health and Therapy
Authorization limits, telehealth place-of-service and time-based code denials.
Labs, Imaging and DME
Medical necessity, frequency and documentation denials.
Across California
We work denials for practices in Los Angeles, Orange County, San Diego, the Inland Empire, the Bay Area, Sacramento, Fresno and the Central Coast, with direct experience in each region's Medi-Cal plans and IPAs. Our denial management services in Los Angeles cover L.A. Care, Health Net, Molina and the county's large IPA and medical group networks.
Specialties
Cardiology · Orthopedics · Radiology · Oncology · Gastroenterology · Dermatology · OB/GYN · Behavioral health · Physical therapy · Pain management · Urgent care · Primary care · Anesthesiology · General surgery · Pediatrics · Nephrology
See all specialties →Results We Hold Ourselves To
Denial Management Pricing That Pays for Itself
| Plan | Pricing | Best for | Includes |
|---|---|---|---|
| Ongoing denial and AR management | 3.5% of monthly collections | Practices that bill in-house but need back-end support | Daily denial capture, corrections, appeals, provider disputes, AR follow-up, monthly root-cause report |
| Aged denial and AR recovery | 18% of dollars recovered | Backlogs and AR over 90 days | Project-based clean-up; you pay only on what we collect |
| Coding denial review | $45 per claim reviewed | Practices with recurring coding denials | Certified coder review, corrected claim or appeal, provider feedback |
| Bundled with medical billing | Included | Practices using our full medical billing service | Denial management and AR follow-up included in your billing rate |
No setup fee and no long-term contract. The free denial audit is no-obligation.
Why Practices Trust Us
- HIPAA-compliant workflows, signed BAA and role-based access
- Certified coders (CPC, CCS) on every coding denial
- Every payer contact logged with date, reference number and outcome
- California-specific dispute expertise: Knox-Keene PDR, IPA appeal rights, Medi-Cal and Medicare appeals
In-House Billing Staff vs Outsourced Denial Management
| In-house team | California Billing Services | |
|---|---|---|
| Speed | Denials worked when time allows | Every denial touched within 48 hours |
| Prioritization | Oldest or easiest first | By dollar value and days left to appeal |
| Coding denials | Billers guess at the fix | Certified coders correct and document |
| California disputes | Plans' deadlines rarely tracked | Knox-Keene PDR clocks tracked and enforced |
| Root cause | Same denials repeat | Monthly fix owners and measured results |
| Underpayments | Rarely caught | Every payment checked against contract |
| Coverage | Gaps during PTO and turnover | Full team backup |
| Cost | Salary, benefits, training, software | From 3.5% of collections, no contract |
If even a fraction of your denials are going unworked today, outsourcing usually pays for itself in the first quarter.
Denial Management Services FAQs
Denial management is the process of recovering payment on claims a payer has refused and preventing the same denials from recurring. It includes reading remittances, classifying denials by reason code, correcting or appealing claims, and fixing the root causes upstream.
Can't find what you're looking for? Contact our billing specialists
Find Out How Much of Your Denied Revenue Is Still Recoverable
Send us 90 days of remittance files. In five business days, a California denial specialist will show you your true denial rate, your top denial reasons by payer, how many dollars are still inside their appeal windows, and the three fixes that would prevent the most denials next month.
HIPAA compliant · BAA provided · No long-term contract · Pay only on recovery for aged claims
What your free audit shows
- Your true denial rate
- Top denial reasons by payer
- Dollars still inside appeal windows
- Three fixes that prevent the most denials
- Delivered in five business days
Stop denials before they start
Most denials begin upstream. These services fix the causes at the source.