Claim denial do's and don'ts

Marketplace plans on HealthCare.gov denied 19% of in-network claims in 2024, per KFF’s review. Sort each month's denials by reason, and fix the top one first.

Chris Hume
Head of Growth and Operations, JotPsych

You have this month's denied claims in front of you, and each one carries a reason code from the payer. You're working them one at a time.

Do sort each month's denials by payer, code, and reason

Count your denials by payer, by billing code, and by reason code. Rank the reasons so you can see which fix to make first, since one reason can repeat across many claims.

Do fix the top reason where it starts

Trace your top reason to the step that caused it. Eligibility denials start at your coverage check, and authorization denials start at your prior authorization step. Fix that step. Then watch next month's count for the same reason.

Do appeal clinical denials with the full record

Clinical notes can answer a medical necessity denial. Send them with the treatment plan and any scores the payer asks for.

Don't wait until the quarter ends to sort

Each month you wait adds a month of claims with the same denial. Sort on the same day each month.

Don't resubmit a denied claim unchanged

You'll get the same denial. Fix the cause the reason code names, then send a corrected claim or an appeal.

Don't write off a denial you haven't read

Your patients rarely appeal a denial themselves. On HealthCare.gov plans, patients appealed fewer than 1% of in-network denied claims in 2024, per KFF’s review of insurer data. Look up the reason code in the X12 code list before you write off the balance, since the fix can be one field, like a corrected member ID.