Rejection
277CAThe claim failed the clearinghouse or payer front-door edits and was never adjudicated. It cannot be appealed. It is corrected and resubmitted, and the filing clock keeps running until a clean claim is accepted.
Denial Management Services for Medical Practices
We work every denial by its reason code, appeal inside each payer's deadline, and fix the front-end and coding problems that cause them, inside the EHR you already use.
- Every denial worked, including the small ones
- 3 to 5% of collections, month to month
- Free RCM audit in 3 to 5 business days
Denial management
Where denials come from
A denial is the payer telling you where the process broke. Most of them trace back to five places, and most of those can be prevented before the claim is sent.
- 01
Eligibility and registration
Coverage that ended, a patient the plan cannot identify, or another payer that should have gone first. In one engagement, these front-desk problems caused 70 percent of the denials.
- 02
Missing authorization
The service needed approval and nobody asked, or the approval did not match what was performed.
- 03
Coding and modifiers
A modifier that does not fit the code, a diagnosis that does not support the procedure, or a service bundled into another one already paid.
- 04
Medical necessity
The payer does not consider the service necessary for the diagnosis billed, often because a coverage policy's diagnosis list or documentation rules were not met.
- 05
Timely filing and duplicates
Claims filed after the window closed, or resubmitted as new claims instead of as corrections.
Definitions
Rejection, denial or adjustment
Denial
835The payer adjudicated the claim and refused all or part of it, with a reason code on the remittance. It is fixed with a corrected claim where the claim was wrong, and appealed where the payer was.
Contractual adjustment
CO-45Reason code 45 means the charge was above the fee schedule or contracted amount. It is not a denial, but it is where underpayments hide, so the allowed amount should be checked against the contract.
Patient responsibility
PRDeductible, coinsurance and copay amounts carry group code PR. They belong on the patient statement, not in an appeal.
Reason codes
The denial codes we see most, and what fixes them
Every adjustment on a remittance carries a group code and a claim adjustment reason code. CO means the provider is responsible under the contract, PR means the patient owes it, OA is another adjustment, and PI is a reduction the payer initiated.
| Reason code | What the payer is saying | What fixes it |
|---|---|---|
| 16 | Claim or service lacks information or has submission or billing errors | Read the remark code, correct the field and resubmit as a corrected claim |
| 27 | Expenses incurred after coverage terminated | Find the current coverage, update the record and bill the right payer |
| 31 | Patient cannot be identified as the payer's insured | Correct the member ID, name or date of birth against the payer record |
| 22 | Care may be covered by another payer per coordination of benefits | Confirm the order of benefits with the patient and bill the primary first |
| 197 | Precertification, authorization or notification absent | Look for an existing approval or a retro-authorization route, then appeal |
| 4 | Procedure code inconsistent with the modifier used | Correct the modifier, or add the one the payer's policy requires |
| 11 | Diagnosis inconsistent with the procedure | Recode from the note, and check the coverage policy's diagnosis list |
| 50 | Not deemed a medical necessity by the payer | Appeal with the note and the coverage criteria it meets |
| 97 | Benefit included in the payment for another service already adjudicated | Check the code pair edit, and use a modifier only where the note shows a distinct service |
| 29 | The time limit for filing has expired | Appeal with proof of timely submission, or write off with a documented reason |
| 18 | Exact duplicate claim or service, reported with group code OA | Check the first claim's status, and send changes as corrected claims, not new ones |
Appeals
Appeal deadlines by payer type
Every level has its own clock, and a missed deadline usually ends the argument. These are the windows we track for each claim.
| Payer and level | Who decides | Deadline to file |
|---|---|---|
| Medicare level 1: redetermination | The Medicare Administrative Contractor | 120 days from receipt of the initial determination |
| Medicare level 2: reconsideration | A Qualified Independent Contractor | 180 days from receipt of the redetermination |
| Medicare level 3: hearing | Office of Medicare Hearings and Appeals | 60 days from receipt of the reconsideration, with a minimum amount in controversy |
| Medicare levels 4 and 5 | Medicare Appeals Council, then federal district court | 60 days from receipt of each decision |
| Medicare Advantage reconsideration | The plan | 60 days from receipt of the organization determination |
| Employer plans under ERISA | The plan, usually with the patient's authorization | At least 180 days after an adverse benefit determination |
| Commercial contracts | The payer | Whatever the provider contract sets, often much shorter |
Medicare presumes a notice arrives five days after its date, and Medicare Advantage plans use the same presumption. A non-contracted provider appealing to a Medicare Advantage plan follows its own route, covered in what to do when a Medicare Advantage plan pays less than Medicare.
Source: 42 CFR 405.942 · 42 CFR 405.962 · 42 CFR 405.1014 · 42 CFR 422.582 · DOL claims procedure FAQs
Prevention
Fixing the cause, not just the claim
Appeals recover money one claim at a time. Prevention stops the next hundred denials. Every week we group denials by reason, payer and provider, and fix the step that produced them.
| Denial type | Where the fix happens |
|---|---|
| Eligibility denials | Coverage verified before each visit, working with your front desk |
| Authorization denials | Requirements checked at scheduling and approvals tracked to expiry |
| Coding and bundling denials | Edits checked before submission, and patterns fed back to the provider |
| Medical necessity denials | Diagnosis and documentation checked against the coverage policy before the claim leaves |
| Timely filing denials | Rejections worked within days, and proof of submission kept for every claim |
Not sure your current billing company does any of this? Read how to tell whether your denials are being worked, and see how to audit billing write-offs.
Comparison
Before and after working with Quilven
A process comparison, not a promise of outcome. It shows what changes in how denials are handled.
| Area | Before | With Quilven |
|---|---|---|
| Triage | Denials worked in date order, or by size, when someone has time. | Denials sorted by reason code and deadline every week. |
| Small claims | Low-dollar denials left to age out. | Every denial worked, including the ones too small to be worth anyone's time. |
| Appeals | Appeals filed late, or without the note and the policy criteria. | Appeals filed inside each level's deadline with the documentation attached. |
| Root causes | The same denial returns every month. | Each pattern traced to the step that caused it, and fixed there. |
| Rejections | Rejected claims sit in the clearinghouse queue until the filing window closes. | Rejections worked within four to five days, while the claim is still recoverable. |
| Write-offs | Adjustments posted without a reason. | Every write-off carries a documented reason you can audit. |
| Reporting | Denial totals with no reason or payer breakdown. | Denials by reason code and payer in Apex, whenever you look. |
Which of these applies to your denials is a question the audit answers. Request the audit.
Case study
Where the $5,500 was hiding
One AR recovery engagement, at a family medicine practice in Minnesota. Shown for method: 70 percent of its denials came from eligibility at the front desk. Individual results vary. One engagement is not a forecast.
We reviewed 245 claims. The rejection queue had no owner, and some claims in it had waited close to a year.
Billed charges in that queue came to roughly $40,000 to $50,000, none of it being worked.
Most of the damage started before the claim was built. Stale coverage, incorrect member IDs and skipped eligibility checks at the front desk caused 70% of the denials.
Not everything could be reopened. On most of the affected claims, a commercial payer's 90-day window had already passed with no proof of submission on file, so appeals were not possible.
What came back was about $5,500, paid on 50 to 55 claims, most of it within 45 to 50 working days.
In their words
What the physician said
What you have provided for me was a detailed of things that are going wrong that needed to change in our practice.
I appreciate that you did an audit and found out the root causes of a lot of my problems which are preventable.
I appreciate the professionalism, the courtesy, the knowledge.
After the audit the practice changed how it runs: eligibility verified before arrival, no more walk-ins, every patient checked the night before.
Pricing
What Quilven costs
Denial management is part of medical billing: 3 to 5 percent of collections with a $500 monthly minimum, the same for every specialty. A backlog of old denials can be worked as an AR recovery project instead. You can see pricing in full.
AR recovery
12 to 15%
of the recovered amount
No fee on what is not recovered. Where a practice lands in the range depends on claim volume, age of the inventory, and payer mix.
Medical billing
3 to 5%
of collections by monthly volume
A $500 monthly minimum applies. The rate moves with monthly volume, not with headcount on your side.
Credentialing
$150 to $200
per payer application
$200 per application, or $150 each on larger batches. Included in the billing percentage for billing clients.
Fit
Fit with your EHR
Denial work does not require a system swap. We integrate with 30+ EHRs and practice management systems and work inside the one you already have. No data migration, no parallel system, no change to how your staff enters a charge or checks a patient in. If your team is trained on your current software, that training stays valid.
This matters because the usual objection to outside denial help is that it turns into an implementation project. It does not here. Quilven is a managed service, not software. There is no proprietary platform you are asked to adopt and no license to renew, so the engagement can start on the denials you already have rather than after a build-out.
What you do get is visibility. Apex is our client dashboard, and it shows in real time:
- Net collection rate
- AR aging by bucket
- Denial reasons by payer
- Credentialing pipeline
Apex reads the work we are doing in your system. It is a window, not a replacement, so if the engagement ends your records and workflows are exactly where they were.
Company
Who Quilven is
Quilven is a managed revenue cycle service. Not software, not an EHR, and not a proprietary platform you have to adopt. We work inside the system your practice already uses, across 30+ integrations, with no data migration and no workflow change. Our clients are independent practices with 3 to 25+ providers.
Pricing is straightforward. AR recovery is 12 to 15 percent of the recovered amount. Medical billing is 3 to 5 percent of collections by monthly volume, with a $500 monthly minimum. Credentialing is $150 to $200 per payer application.
The entry point is a free RCM audit. It takes 3 to 5 business days and returns a line-by-line recoverable revenue estimate by payer, so the first thing you get from us is a diagnosis you can act on with or without us.
We lead with method and evidence rather than tenure. Quilven was founded in 2025 by Raief Shick and works from 159 4th Ave N, Suite 100, Nashville, TN 37219. The entity is registered in Wyoming. Reach us at (202) 490-9406 or info@quilven.com.
Fit
Who this is for
Independent, physician-owned practices with 3 to 25+ providers whose denials are growing, or whose billing company submits claims but does not work them. Solo practices are welcome too.
If the problem is a backlog rather than the weekly flow, start with aged AR cleanup. If claims are not going out clean in the first place, see medical coding and medical billing.
It is not for hospitals billing facility claims.
At a glance
Denial management service facts
- Service
- Denial management for independent practices
- Covers
- Rejections, denials by CARC and RARC, corrected claims, appeals at every level, root-cause fixes, write-off review
- Delivery model
- Managed service, not software, not an EHR
- Systems
- 30+ EHR and practice management integrations, no data migration
- Practice size served
- 3 to 25+ providers, independent and physician-owned; solo practices welcome
- Pricing
- Part of medical billing: 3 to 5% of collections, $500 monthly minimum
- Entry point
- Free RCM audit, 3 to 5 business days, recoverable estimate by payer
- Reporting
- Apex dashboard: denial reasons by payer, AR aging by bucket, net collection rate
- Area served
- United States
- Data handling
- Aging totals only to start, no patient data required
FAQ
Denial management questions
A rejection never reached adjudication: the clearinghouse or payer refused the claim at the door, so it is corrected and resubmitted. A denial was adjudicated and refused with a reason code, so it is corrected or appealed.
120 days from receipt of the initial determination to request a redetermination, then 180 days for a reconsideration, then 60 days for a hearing. Medicare presumes you received each notice five days after its date.
No. Reason code 45 means the charge was above the fee schedule or contracted amount, so the difference is adjusted off. It is still worth checking, because underpayments hide in the allowed amount.
Yes. Every denial is worked, including the ones too small to be worth anyone's time, because small denials are usually the visible end of a bigger pattern.
It is part of medical billing: 3 to 5 percent of collections, with a $500 monthly minimum. A backlog of old denials can be worked as an AR recovery project at 12 to 15 percent of what is recovered.
Every claim's status is visible in Apex, including the ones still open, so unworked denials show up in the report. Ask any billing company for the same view before you sign.
Sources
Sources
Checked 17 October 2026. Coverage policies and code rules revise without much notice, so confirm the current version before you rely on one.
- X12, Claim Adjustment Reason Codes and group codes
- eCFR, 42 CFR 405.942, time frame for filing a redetermination
- eCFR, 42 CFR 405.962, time frame for filing a reconsideration
- eCFR, 42 CFR 405.1014, request for an ALJ hearing
- eCFR, 42 CFR 422.582, Medicare Advantage reconsideration requests
- US Department of Labor, benefit claims procedure regulation FAQs (ERISA)
- CMS, Medicare fee-for-service appeals
Next step
Start with a free RCM audit
The audit takes 3 to 5 business days and returns a line-by-line recoverable revenue estimate by payer, plus the repeating root causes behind your denials. We only need aging totals to begin. No patient data, no contract, no obligation to work with us afterward. If your aging is healthy we will tell you that.
Answer three questions below and book a line-by-line audit of your denials.
Where it leaks
Oldest claim
Practice size
Your details
Where is the money leaking right now?
Pick the one that hurts most. We start there.
How old is your oldest unpaid claim?
A round number is fine. We verify it in the audit.
How big is the practice?
Just you, or a group. Either is welcome.
Last bit — where do we send the report?
No patient data. We only need aging totals to start.
(202) 490-9406 · info@quilven.com · Book 15 minutes