Denial Management & Appeals

A denial means a payer processed a claim and chose not to pay all or part of it. Some denials are simple fixes. Others need medical records, a letter, or a formal appeal. Left alone, they become write-offs.

Denial management services do two jobs. First, they work each denied claim: find the reason, correct or appeal it, and track the result. Second, they study the patterns and fix the cause, so the same denials stop coming back.

Westmont Revenue Partners connects practices and facilities with vetted medical billing experts who provide outsourced denial management. We match you with a team that knows your specialty, your payers, and your documentation.

Who this is for

Practices with rising denial volume or a pile of old denied claims
Specialties with frequent medical necessity, authorization, or coding denials
Groups without staff time to write appeals
Practices that write off denials because follow-up is too slow
Facilities with high-dollar claims where each denial matters
Owners who want to know why claims are denied, not just that they are

What's included

Daily review of denials from remittance advice and payer portals
Sorting of denials by cause, payer, provider, and dollar value
Correction and resubmission of claims denied for fixable errors
Preparation of appeals, with supporting records and clear arguments
Requests for reconsideration and peer-to-peer reviews, when a payer offers them
Tracking of appeal deadlines and payer-specific appeal rules
Escalation of unresolved issues to payer representatives
Root-cause analysis shared with front desk, coding, and clinical staff
Prevention suggestions such as better authorization or documentation steps
Reporting on denial trends, recovery, and write-offs

How it works

Denials are pulled from remittance advice and payer portals and logged.
Each denial is classified by reason, such as eligibility, authorization, coding, or medical necessity.
Fixable errors are corrected and resubmitted. Others go to an appeal path.
Appeals are prepared with records and sent before the payer deadline.
Results are tracked until the claim is paid, upheld, or closed.
Trends are reviewed with your team, and upstream fixes are recommended.

Common challenges

Unclear denial reasons. Remittance codes are short, and payer letters can be vague. An experienced biller reads the codes together with the payer policy to find the real reason.
Missed appeal deadlines. Payers set their own windows, and Medicare redetermination requests generally must be filed within 120 days of receiving the initial determination. Billers log deadlines the day a denial arrives.
Authorization denials. A missing or mismatched authorization can end a claim. Billers check whether it was obtained, whether it covers the service, and whether a retro request is possible.
Medical necessity denials. These often turn on diagnosis support and notes. Billers work with clinicians to supply the right records and cite payer policy.
Coding and bundling denials. Payers may question modifiers or combined services. Billers review the coding with a certified coder before appealing.
Eligibility and coordination of benefits. Wrong coverage on file leads to denials. Billers verify coverage and send claims to the correct payer.
Low-dollar denials ignored. Small denials add up. Billers set rules so repeating low-dollar issues are fixed at the source.
Timely filing denials. Late claims are hard to win. Billers collect proof of timely submission, such as clearinghouse acknowledgments.

Metrics worth tracking

Denial rate: share of claims denied; shows overall claim health.
Denial reasons by payer and provider: shows where to focus prevention.
Appeal overturn rate: share of appeals that win; shows how well appeals are built.
Net recovery on denials: dollars recovered; shows return on follow-up.
Days to resolve a denial: shows how quickly cash comes back.
Write-offs for denials: shows what is lost, and why.
Preventable denial share: denials rooted in front-end or coding errors that can be stopped.

Codes and standards

Code or standard	Type	What it covers
CARC (Claim Adjustment Reason Codes)	Code set	Explain why a claim or service line was paid differently than billed
RARC (Remittance Advice Remark Codes)	Code set	Add detail to a CARC or give alerts; many are supplemental to a CARC
835 (005010X221)	EDI transaction	Electronic remittance advice that carries denial and adjustment data
276/277 (005010X212)	EDI transaction	Claim status request and response
837 Professional and Institutional	EDI transaction	Electronic claims, including corrected claims
42 CFR 405.942	Regulation	Medicare time limit for filing a redetermination request (first appeal level)

Note

Codes and standards are examples for orientation, not a complete list, and do not guarantee coverage or payment. Always check current code sets and payer policy.

Specialties that use this service

How Westmont can help

We match you with vetted billing experts experienced in denial management and appeals.
We look for teams familiar with your specialty's common denials and payer rules.
We help you find providers who report on root causes, not only on recoveries.
We start with a conversation about your denial mix so the match fits.

Frequently asked questions

What is denial management?

Denial management is the work of finding why claims were denied, correcting or appealing them, and preventing repeats. It combines claim follow-up, appeal writing, and trend analysis. Strong programs treat denials as a signal about front-end and coding processes, not just a collections task.

How long do I have to appeal a denial?

It depends on the payer and the plan. Medicare fee-for-service generally allows 120 days from receiving the initial determination for the first appeal level. Commercial payers set their own windows, often in the contract or denial letter. Check each payer's current rules and act early.

Is it worth appealing small denials?

Often yes, especially when the same issue repeats. A single small denial may not justify a long appeal. A pattern of them might add up to real money. Good billers fix the cause and use quick corrections for low-dollar cases.

What are CARC and RARC codes?

CARCs explain why a payer adjusted a claim or line. RARCs add detail or alerts to the remittance. Together they show the reason for a denial or short payment. Each payer uses them a bit differently, so billers read them alongside payer policy.

Can denial management reduce future denials?

Yes, when the biller shares findings. If many denials come from missing authorizations or one coding habit, your team can change the workflow. The goal of a denial management company is fewer denials over time, not just more appeals.

Related services

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