How it works
It's a cycle, not a checklist.
Each stage depends on the one before it. Get eligibility wrong and the denial shows up four steps later, which is why we run the whole loop rather than picking up at submission.
- 01
Verify Eligibility
Coverage confirmed before the visit, so surprises don't show up at claim time.
- 02
Capture & Code
Every service documented and coded correctly the first time.
- 03
Submit Claim
Clean claims sent to the payer, scrubbed for errors beforehand.
- 04
Adjudicate
Claims tracked through review; denials are caught and fixed fast.
- 05
Post Payment
Payments reconciled against the original claim, down to the line item.
- 06
Follow Up AR
Unpaid claims followed until resolved, then the cycle starts again.
Denial reference
What the codes actually mean.
These are standard CARC values every practice sees. Knowing which ones are fixable, and which ones are already lost, is most of denial management.
Claim lacks information, or has a submission or billing error
The broadest denial there is, and usually paired with a remark code that names the real problem. We read the remark, correct the field, and resubmit.
Benefit is included in the payment for another service
A bundling denial. We check whether the services were genuinely separate and, where they were, appeal with the modifier and documentation that supports unbundling.
The diagnosis is inconsistent with the procedure
Usually a linkage problem rather than a coding one. We reconcile the diagnosis pointer against the documentation and correct the pairing.
Procedure code is inconsistent with the modifier, or a required modifier is missing
We identify which modifier the payer expects for that code and place of service, then resubmit rather than writing it off.
Precertification or authorization is absent
Often preventable upstream. We pursue retroactive authorization where the payer allows it, and move the check earlier in the process so it doesn't recur.
The time limit for filing has expired
The one denial that can't be argued once it lands. We work AR by deadline proximity specifically so claims don't reach this code.
Charge exceeds the fee schedule or maximum allowable
Usually contractual rather than an error, but not always. We check the posted allowable against your contracted rate and dispute genuine underpayments.
Exact duplicate claim or service
Often a symptom of resubmitting without a corrected-claim indicator. We confirm the original's status before anything goes out again.
Want to see where your cycle breaks down?
We'll walk your current process stage by stage and show you where claims are stalling.