Denial Management & Appeals

Denials are triaged the moment they arrive. Each is classified by denial reason with an estimated likelihood of a successful appeal, and a payer-specific appeal letter is drafted and ready for review.

1. Ingest — the denial is captured (from a prior-auth case or posted remittance).
2. Classify — denial reason + win-likelihood are determined.
3. Strategize — the strongest appeal angle is selected.
4. Draft — a payer-specific appeal letter is composed.
5. Gate — approve or edit the appeal before it goes out.
6. Submit → Decide → Learn — the outcome updates future win-likelihood estimates.

Appeal letters are drafted but never submitted without approval.

Billers and reviewers own denials; clinicians add clinical justification when needed.

Appeal outcomes feed back so win-likelihood estimates get more accurate for each payer and denial type.