Denials Management – Organization for Success

Beth Jones, Director Revenue Cycle Solutions Project Manager

Trilogy Revenue Cycle Solutions

The struggle to manage denials is real. Most facilities do their best to keep up but are often overwhelmed about where to start.

Create a Team

Create a Denials Management Team with a defined leader, C-Suite executive support, leaders from each revenue cycle area, such as Billing, Patient Access, HIM/Coding, Case Management and I.T.  Define objectives and team responsibilities, reporting, goals, monitoring, KPI review and round table discussions. Don’t just talk about it. Take actions! Here are a few key functions to consider.

Check Your System

Each Electronic Health Record (E.H.R.) patient accounting system has a file maintenance table for appropriately classifying both CARC (Claim Adjustment Reason Codes) and RARC (Remittance Advice Remark Codes). Review current settings with Washington Publishing /CMS codes (291 codes available) and see WPC (Washington Publishing Company) complete list. We often discover most manual work can and should be automated if the system is set up correctly. This is a crucial step to complete.

Talk to the back-end billing/collections staff assigned to work partial payments/denials. Are they manually writing off balances off that should be automated? Are denied charges included in the contractual adjustments or patient responsibility? Do staff move copay, deductibles, and coinsurance to patient responsibility?

Also review the Claim Adjustment Group Codes grouped with the CARC code on the EOB. These codes along with the CARC code are associated with an adjustment, meaning they must communicate why a claim or service line was paid differently than it was billed. Each CARC should have a Group Code assigned so as to identify how the payment/denial is further handled within your system. This review is payor specific. Below are the 5 EOB claim adjustment Group Codes:

CO- Contractual Obligation

CR- Corrections and Reversal

OA- Other Adjustment

PI- Payer Initiated reductions

PR- Patient Responsibility

Make the necessary system updates internally or place a service request ticket to table file owner. This process takes time and is cumbersome to complete. Make sure you assign this to someone who understands how the settings affect patient balances and are payor defined. Example: Blue Cross Blue Shield may be different than Medicare or Medicaid. This exercise takes the longest to complete but is the foundation for routing workflow.


Once your table files are set appropriately, analyze data daily, weekly, and monthly:

  • 835 EDI remit denials
  • Accounts written off due to denials by transaction alias
  • Sort out the top denials by reason for highest balances and # of denials

You will uncover issues that need to be addressed with Coding, Billing, Registration, Case Management and Managed Care staff as well as clinical documentation by providers/physicians and nurse practitioners.

Education and Communication

There is a difference in a denied vs a rejected claim. Staff education is key. Investigation skills are a requirement for billing staff to perform a root cause analysis. Educate staff to review the EOB/ERA for insight into root cause and potential resolution. When all else fails call the payor.

It is important to educate staff on payer specific appeals and claim resubmissions processes. Develop cheat sheets for clinical and technical appeals teams by payor such as:

  • appeal templates, claim submission timely filing limits, appeal timely filing limits, and payor address/electronic submission instructions

Set Goals/Measure

Set goals based on industry standards and best practices. Measure denial KPIs and report them in monthly denial meetings. HFMA has map keys to calculate denial metrics several different ways and for trending indicators of denied claims.  Review and measure what is best for your facility.

Develop an internal policy for denials management. Outline each area’s responsibility, meet at least monthly to measure, monitor/audit, and repeat. If you need assistance building your denials management program or an assessment of your revenue cycle operations, you can contact Trilogy Revenue Cycle Solutions for assistance in getting your organization set up for success.

Beth Jones

Director, Revenue Cycle Solutions Project Manager

[email protected]


November 12th, 2021