Repeat denial do's and don'ts
The same reason code every month points to one step that fails and one person who controls that step.
Co-founder, JotPsych
You fix and resend each denied claim. Next month the same reason code comes back. Your resend fixed the claim but didn't fix the step that failed. Find that step.
Count your denials by reason code
Find the step behind your top code and the person who controls that step
Call the payer when the code says too little
Resending without finding the cause
Assuming the step behind the code was done right
Keeping the fix inside billing
Phillips's rule: every denial needs a root cause. You stop next month's denial by changing the step that fails, not by resending this month's claim.
Three do's for a repeat denial.
Count your denials by reason code.
Pull last quarter's denials from your billing system, and group them by the reason code on each claim. Each code comes from a national list kept by X12, the standards body for electronic claims. Start with your top code.
| Code | The payer's reason, in X12's words | Step to check first, and who owns it |
|---|---|---|
| 197 | Precertification/authorization/notification/pre-treatment absent. | Prior authorization at intake: front desk or intake staff |
| 50 | These are non-covered services because this is not deemed a 'medical necessity' by the payer. | Medical necessity in the note: the clinician |
| 16 | Claim/service lacks information or has submission/billing error(s). | The fields on the claim: the biller |
X12's list of claim adjustment reason codes, last reviewed August 1, 2026, read October 1, 2026. A code that repeats month after month points to the same step, and the person who controls that step can change it.
Find the step behind your top code and the person who controls that step.
Read three of your claims with that code, and find the step where each claim went wrong. Then name the person in your practice who controls the step, such as the front desk for a missing authorization.
Jessica Phillips, chief operating officer of an anesthesia practice in Roanoke, Virginia, sets the rule for her team: "every denial needs a root cause attribution." Her reason: "We need to know why something is happening and who can control it."
Call the payer when the code says too little.
Ask the payer what's missing from your claim. Some denials say only "insurance does not pay for this," Phillips said, and "if you don't call, you won't figure out what the denial is actually for."
Three don'ts for a repeat denial.
Don't resend without finding the cause.
Write the cause on each denied claim before you resend the claim, so your next count shows each cause beside its code.
Don't assume the step behind the code was done right.
Ask for proof. For a code 197 denial, ask the front desk for the authorization number on file. For a code 50 denial, ask the clinician to show you where the note states why the visit was needed.
Don't keep the fix inside billing.
You find the cause. In Phillips's rule, the root cause "will come from the team that is actually working those denials." The person who controls the step makes the fix, so teach the fix to that person: the front desk for authorizations, the clinician for medical necessity.
In JotPsych, set the Claim problem filter to Denied, and each denied claim's payment record shows its reason code.
Book 15 minutes- Jessica Phillips, chief operating officer of Anesthesiology Consultants of Virginia, and Deepak Sharma, “The Rural Health Revenue Problem No Dashboard Shows,” session D5, Medical Group Management Association (MGMA) 2026 Annual Conference, San Antonio, September 28, 2026.
- X12, Claim Adjustment Reason Codes, codes 16, 50, and 197; list last reviewed August 1, 2026; read October 1, 2026.