Understand your denials. Plan the next review.

How to review a denied claim

A denial is the payer's answer to a specific claim on a specific date of service, so a useful review starts with the remittance rather than with a guess. The 835 ERA or paper EOB carries a claim adjustment group code and one or more claim adjustment reason codes (CARCs), often with remittance advice remark codes (RARCs) that narrow down what the payer wants. Read those codes against the current X12 code lists before deciding whether the claim needs a correction, a reconsideration or a formal appeal.

What the group code tells you

• CO (contractual obligation): the provider is responsible, so the amount cannot be billed to the patient.
• PR (patient responsibility): deductible, coinsurance, copay or a non-covered service the patient agreed to.
• OA (other adjustment): neither of the above, for example a coordination-of-benefits adjustment.
• PI (payer-initiated reduction): a payer reduction that is not contractual and not the patient's responsibility.

A four-step review

1. Collect the EOB or ERA, the claim as submitted, the payer policy and the supporting documentation.
2. Confirm the reason code in the current code list and check coverage and contract terms for the date of service.
3. Check eligibility, authorization, coding and documentation before choosing between a corrected claim and an appeal.
4. Record the filing deadline, the owner and the next action, then track outcomes against your own baseline.

Where each specialty's denials usually start

Family Medicine

Modifier 25 on same-day E/M + procedure, and under-captured AWV/CCM revenue.

Cardiology

NCCI bundling on echo/stress tests and component (26/TC) modifier errors.

Orthopedics

Prior-authorization gaps on surgery/imaging and global-period modifier (58/78/79) errors.

Dermatology

Cosmetic-vs-medical non-covered denials and lesion size/count documentation.

Behavioral Health

Time-based therapy code downcoding and payer visit-limit/authorization rules.

Gastroenterology

Screening-vs-diagnostic colonoscopy (modifier 33/PT) and multiple-endoscopy rules.

Internal Medicine

E/M downcoding on complex visits and uncaptured CCM/TCM care-management revenue.

Pediatrics

Under-billed vaccine administration codes and well-vs-sick same-day visits.