Denials Intelligence & Recovery Engine
Most denial reports give you very little actionable information. They give you a claim line item and your adjustment codes, no real insight. Your team is left sorting through a flat list, guessing which claims are worth chasing and which ones aren't, without a clear path to action.
This engine reads your 835 remittance files, reads the CARC and RARC codes inside them, and categorizes every denial by the type of action it needs, whether that's a coding correction, a missing authorization, a credentialing gap, or a documentation issue. Then it ranks every recoverable denial by recovery potential and dollar value so your team always works the highest value claims first. The same intelligence also feeds back into the Pre-flight Claims Engine, so future procedures with the same patterns get flagged before they ever leave your system.
Five Steps from Remittance File to Recovery Plan
The engine reads the remit and analyzes the denial, then groups denials by denial category, puts the most recoverable ones at the top of your worklist, and feeds the patterns back into Pre-flight so the same denials do not repeat.
Reads 835 Remittance Files
The engine ingests the electronic remittance files your payers send back after adjudication. These are the files that tell you what was paid, what was adjusted, and what was denied, line by line.
Reads Adjustment and Remark Codes
Every denial carries a Claim Adjustment Reason Code (CARC) and often a Remittance Advice Remark Code (RARC). The engine reads both and uses that combination to understand exactly why the payer denied or underpaid the claim or procedure.
Sorts Denials by Action Needed
Once the engine understands why a denial happened, it sorts it into the category that matches what needs to happen next. Common categories include Coding, Billing, Credentialing, Coordination of Benefits, Authorization, and Plan Limitation Reviews. Each denial is routed to the appropriate category, which allows you to understand the next step without hours of research.
Ranks by Recovery Potential
Not every denial is worth the same effort. The engine scores each recoverable denial by the dollar amount at stake, the likelihood of recovery based on the denial type, and the recommended action. Your worklist sorts claims with the highest dollar value and highest recovery potential to the top, so you can focus on the real revenue.
Feeds the Pre-flight Engine
Every denial the engine processes becomes a signal. The procedure and denial patterns identified here are written back into the denial patterns database that the Pre-flight Claims Engine reads on every future submission. This turns each denial worked today into a preventable denial tomorrow.
Recovery Prioritization Dashboard
This is the centerpiece of the engine. Every denied claim is ranked by recovery potential, so your team knows exactly where to start each morning. The recommended action tells them what to do, not just what happened.
| Rank | Claim ID | Patient | CPT | Denied | Recovery $ | Probability | CARC | Recommended Action |
|---|---|---|---|---|---|---|---|---|
| 1 | CLM0001 | Sarah Chen | 99214 | $1,250 | $1,150 | 92% | CARC 23 | Immediate Appeal Authorization may be obtainable |
| 2 | CLM0017 | Carlos Torres | 93306 | $980 | $735 | 75% | CARC 119 | Standard Appeal Coding correction needed |
| 3 | CLM0042 | Thanh Nguyen | 70553 | $1,500 | $1,200 | 80% | CARC 23 | Immediate Appeal Pre-auth retrieval |
| 4 | CLM0068 | Angela Williams | 99213 | $480 | $312 | 65% | CARC 27 | Standard Appeal Medical necessity documentation |
| 5 | CLM0083 | Robert Chen | 20610 | $320 | $128 | 40% | CARC 97 | Observe Contractual, harder to recover |
| 6 | CLM0099 | Elena Rodriguez | 99214 | $185 | $130 | 70% | CARC 21 | Standard Appeal Diagnosis code clarification |
Fictitious patient names for illustration. Standardized fields match the engine's real output schema. Action recommendations are based on CARC code logic and historical recovery rates for each denial category.
Top 5 adjustment codes in this sample, with claim counts and total amounts.
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