Solutions / Denial Management
Denial management
Fix the reason for the denial, not just the claim.
BillCycle reads every denial from your ERAs, groups them by root cause, drafts appeals for your team to review and shows you which upstream fix will stop them for good.
- Every CARC and RARC translated into plain language
- AI groups denials by root cause
- Appeal letters drafted for human review
Last 30 days 103 denials · $69.1K
Root cause, not reason code
Hundreds of denial codes. A handful of real problems.
A denial arrives as a Claim Adjustment Reason Code (CARC) and often a Remittance Advice Remark Code (RARC). On their own they are hard to act on. BillCycle’s AI reads the codes, the claim and the payer together, then classifies each denial by what actually went wrong.
Eligibility and coverage
CARC 27 or 31: coverage terminated or patient not identified. Usually a registration or eligibility issue at the front desk.
Authorization
CARC 197: precertification or authorization absent. Points to the referral and auth process.
Coding and bundling
CARC 97 or 4: service bundled or modifier inconsistent. Often a modifier 25 or 59 documentation gap.
Timely filing and duplicates
CARC 29 or 18: filing limit expired or duplicate claim. Usually a follow-up or resubmission process issue.
How denials are worked
From ERA to appeal in one queue.
Denials are captured the moment the 835 posts, so your team starts working them while the appeal window is still wide open.
01
Capture
Denied and partially denied lines are pulled from the ERA automatically, with group codes (CO, PR, OA) kept intact.
02
Classify
AI assigns a root cause and a recommended action: correct and resubmit, appeal, bill the patient or write off.
03
Prioritize
Denials are ranked by dollar value and days left in the payer’s appeal window.
04
Resolve
Billers correct the claim, send a reconsideration or approve an AI-drafted appeal, and the outcome is tracked.
AI-drafted appeals
Appeal letters drafted in minutes, approved by your team.
For denials worth appealing, BillCycle drafts a letter using the claim data, the denial codes and the relevant payer policy. Your biller reviews it, adds clinical documentation and decides whether to send. Nothing goes to a payer without a person approving it.
Specific to the denial
A medical necessity appeal reads differently from a bundling dispute. The draft matches the reason.
Editable before sending
Billers edit the draft, attach records and keep templates for payers they appeal often.
Tracked to the outcome
Appeal level, send date and response are saved, so you know which appeals actually win.
| Claim | Payer | Status | Age | Amount | Next |
|---|---|---|---|---|---|
| #48213 | BCBS PPO | Rejected | 2d | $225 | Fix modifier |
| #48207 | Aetna | No response | 84d | $3,615 | Call payer |
| #48190 | Medicare | In process | 12d | $860 | Wait |
| #48172 | UHC | Denied CO-16 | 21d | $1,140 | Add info |
| #48165 | Cigna | Paid | 18d | $410 | Done |
Prevention
Stop the same denial from coming back next month.
Working denials recovers money. Fixing the cause keeps it from being lost again.
Denial trends by source
See denials by payer, provider, location, CPT code and root cause, with the dollars attached to each.
Feedback into scrubbing
When a denial pattern repeats, turn it into a scrubbing rule so the next claim is caught before it goes out.
Front desk and provider feedback
Share eligibility, auth and documentation denials with the team that can fix them, with real examples.
Placeholder until a customer approves it
[Customer quote about reducing repeat denials or recovering denied revenue.]
[Name], [Title], [Practice]
[X]% [Verified result, e.g. reduction in repeat denials]
FAQ
Denial management questions
Where do denials come from in BillCycle?
From your electronic remittance advice (ERA, the 835 file). Denials on paper EOBs can be entered manually and are worked the same way.
What is the difference between a CARC and a RARC?
A CARC says why the payment was adjusted, for example CARC 50, not medically necessary. A RARC adds detail, like which information was missing. BillCycle shows both in plain language.
Does the AI send appeals on its own?
No. AI drafts the appeal. A biller reviews, edits and approves it before anything is sent.
How do you keep track of appeal deadlines?
Each payer’s appeal window is stored in BillCycle. Every denial shows the days remaining, and denials near the deadline move up the queue.
Can we see which denials are costing us the most?
Yes. Denial reports break down dollars by root cause, payer, provider and code, so you can focus on the biggest fixable problems first.
Find out what your denials are really telling you.
Share a recent 835 file or denial report and we will show you your denials grouped by root cause in BillCycle.