Denial Guides
Structured AR resolution workflows by denial category — what the denial means, what to verify, recommended next actions, documentation, escalation and QA checkpoints.
All denial guides are AR Guide editorial content: general practice guidance, never payer-specific policy. Always confirm specifics with the payer.
Start here
1 guideThe front-door decision: is this a correction, an appeal, or no action?
Filing
3 guidesSubmission deadlines and claims that need correction or documentation.
- Timely FilingThe payer denied the claim because it was submitted after the filing deadline. Success depends on proving timely submission or finding a valid extension.
- Missing InformationThe claim was missing required information or had a submission or billing error, so the payer could not process it. This is usually a correction, not an appeal.
- Documentation RequiredThe payer requested medical records, orders, notes, certificates, or other documentation before it will process the claim.
Coverage
3 guidesWhether the service is covered under the patient's plan.
- Eligibility & CoverageCoverage could not be verified or was not active for the date of service — member not found, coverage lapsed, or eligibility requirements not met.
- Non-Covered ServicesThe service is not covered under the patient's benefit plan — an exclusion, a coverage limit, or a service the plan simply does not include.
- Medical NecessityThe payer determined the service was not medically necessary or reasonable according to its policy. These denials are documentation-driven.
Approvals
2 guidesAuthorization, referral and pre-treatment requirements.
- AuthorizationThe service required prior authorization, precertification, or pre-treatment review that was missing, expired, or did not cover what was billed.
- ReferralThe service required a referral from a primary care or network provider that was missing, expired, or did not cover the billed service.
Billing
3 guidesCoding, duplicates and bundled or included services.
- Coding & ModifiersThe payer identified a coding issue — a mismatched or missing modifier, an inconsistent diagnosis, a revenue-code mismatch, or an unbundled service.
- Duplicate ClaimsThe payer identified the claim as a duplicate of a previously processed claim. Verify the original before doing anything — this is often a no-action item.
- Bundling & Included ServicesThe payment for this service is included in the payment for another service — a global period, an NCCI edit, or a plan rule that bundles the service.
Payer & patient
4 guidesCOB, the wrong payer, patient responsibility and credentialing.
- Coordination of BenefitsAnother plan may be primary, the primary's payment was not applied correctly, or the claim belongs with a different payer under COB rules.
- Incorrect PayerThe claim was submitted to the wrong payer or plan type and must be sent to the payer that actually covers the service.
- Patient ResponsibilityThe amount is the patient's responsibility under the plan — deductible, coinsurance, copayment, or a non-covered amount the patient may be billed.
- Provider & CredentialingThe provider type, enrollment, credentialing, network status, or facility certification does not support payment for the service billed.