> ## Documentation Index
> Fetch the complete documentation index at: https://mso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Work the denial queue

> Daily triage by CARC group, a fixed root-cause taxonomy, the fix-versus-appeal decision tree, aging rules, and the prevention feedback loop.

The **denial queue** is where every adjudicated claim that wasn't paid in full goes. Working it well means two things: recovering the money, and — the part most practices skip — feeding root causes back upstream so the same denial stops happening.

## Prerequisites

* Posting configured so denials route to the queue rather than to write-off
* A fixed root-cause taxonomy
* Appeal deadlines recorded per payer
* Fee schedules loaded, so underpayments surface

## The daily loop

<Steps>
  <Step title="Triage new denials by CARC family">
    Group them, because the fix is per-family rather than per-claim:

    | Family                     | CARCs           | Typical fix                                                    |
    | -------------------------- | --------------- | -------------------------------------------------------------- |
    | Eligibility                | 26, 27, 31, 32  | Verify coverage, correct the insurance record, rebill          |
    | Authorization              | 197, 198        | Corrected claim with the auth number, or retro-auth, or appeal |
    | Coding / medical necessity | 11, 16, 50, 167 | Review documentation; correct or appeal with policy citation   |
    | Bundling                   | 97              | Verify NCCI edits; modifier if clinically justified            |
    | Timely filing              | 29              | Appeal with proof of submission                                |
    | Coordination of benefits   | 22, 23          | Determine order; bill primary; patient may need to update COB  |
    | Credentialing / enrollment | 8, 185, 206     | Resolve with payer enrollment, then rebill                     |
    | Duplicate                  | 18              | Usually you resubmitted instead of correcting                  |
    | Non-covered                | 96, 204         | Benefit design, patient responsibility or write-off            |
  </Step>

  <Step title="Prioritize by dollars, not by count">
    Ten $40 denials matter less than one $900 denial. Sort the queue by amount, descending, within age bands.
  </Step>

  <Step title="Decide: correct or appeal">
    ```mermaid theme={null}
    graph TB
    A[Denial] --> B{Was the claim data wrong?}
    B -->|Yes| C[Corrected claim<br/>frequency code 7<br/>reference original]
    B -->|No| D{Was the payer's<br/>determination wrong?}
    D -->|Yes| E[Formal appeal<br/>with policy citation]
    D -->|No| F{Patient responsibility<br/>under the contract?}
    F -->|Yes| G[Move to patient ledger]
    F -->|No| H[Write off, with a<br/>root-cause tag]
    ```

    |          | Corrected claim                       | Appeal                                   |
    | -------- | ------------------------------------- | ---------------------------------------- |
    | Use when | The claim had wrong or missing data   | The claim was right; the payer was wrong |
    | Speed    | Days to weeks                         | Weeks to months                          |
    | Deadline | Corrected-claim window, often shorter | Appeal window per contract               |
  </Step>

  <Step title="Tag the root cause from a fixed taxonomy">
    Eligibility · Authorization · Coding · Documentation · Credentialing · Timely filing · COB · Demographic error · Payer error · Benefit design.

    **Free-text root causes are useless in aggregate**, which defeats the entire point of tagging. Use a closed list.
  </Step>

  <Step title="Enforce the aging rule">
    **No denial sits untouched longer than 14 days.** Appeal windows are short, and a denial nobody has looked at is a denial you are about to lose.

    Make the age of the oldest untouched denial a tracked metric.
  </Step>

  <Step title="Close the prevention loop weekly">
    Rank root causes by dollars. Change **one upstream control per week**. Verify next week that the cause dropped.

    Prefer structural fixes, a scrubber edit, over checklist items. See [Build the billing rhythm](/start/first-90-days/build-the-billing-rhythm).
  </Step>
</Steps>

## What not to write off

<Warning>
  **A CO-denial cannot be billed to the patient.** Group code CO means contractual obligation — the patient did nothing wrong. CO-197 (missing authorization) is the common example. Billing the patient breaches your participation agreement.

  And **do not write off a denial before assessing appeal rights.** A write-off is a decision to abandon the money, and it should be a deliberate one with a root-cause tag, not a default.
</Warning>

## Underpayments belong here too

An underpayment doesn't announce itself — the money arrives and the claim closes. With fee schedules loaded, your posting flags allowed amounts below the contracted rate.

Underpayment is usually **systematic**, not random: a payer that loaded your contract wrong underpays every instance of the affected codes. **Aggregate before disputing** — one $12 shortfall isn't worth a call; two hundred instances of the same $12 shortfall is a configuration error worth a formal dispute, and the correction is retroactive. See [Underpayments and contracts](/concepts/payments/underpayments-and-contracts).

## Metrics for the queue

| Metric                               | Target                                  |
| ------------------------------------ | --------------------------------------- |
| Denial rate                          | Under 5–10% of adjudicated lines        |
| Oldest untouched denial              | Under 14 days                           |
| Denials resolved within 30 days      | 80%+                                    |
| Appeal overturn rate                 | Track your own, by payer and reason     |
| Denial write-off as % of net revenue | Under 1–2%                              |
| Top root cause by dollars            | Should change over time as you fix them |

That last one is the real signal. If the same root cause tops the list for three months, your prevention loop isn't working.

## Verify it worked

* [ ] Denials route to the queue, not to auto-write-off
* [ ] Triaged by CARC family, prioritized by dollars
* [ ] Fixed root-cause taxonomy in use
* [ ] Nothing untouched over 14 days
* [ ] Corrected claims use frequency codes and reference the original
* [ ] CO-denials never billed to patients
* [ ] Underpayments flagged and aggregated
* [ ] One upstream control changed per week, and verified

## Common failure modes

| Failure                                         | Consequence                    |
| ----------------------------------------------- | ------------------------------ |
| Working by date received rather than by dollars | Small denials consume the time |
| Free-text root causes                           | No aggregate signal            |
| Denials aging past appeal windows               | Unrecoverable                  |
| Resubmitting instead of correcting              | CARC 18 duplicates             |
| Writing off before assessing appeal rights      | Abandoned recoverable revenue  |
| Billing patients for CO-denials                 | Contract breach                |
| Working the queue but never changing upstream   | The same denials, forever      |


## Related topics

- [Your first denial](/start/first-90-days/work-your-first-denial.md)
- [File appeals](/guides/billing/file-appeals.md)
- [Beat timely filing limits](/guides/billing/beat-timely-filing.md)
- [Post payments from 835s](/guides/billing/post-payments-from-835s.md)
- [Claim denials, explained](/concepts/payments/claim-denials.md)
- [Underpayments, fee schedules, and payer contracts](/concepts/payments/underpayments-and-contracts.md)
- [Denial code playbook](/reference/edi/denial-code-playbook.md)
- [CARC codes (Claim Adjustment Reason Codes)](/reference/edi/carc-codes.md)