Denial management that connects recovery work to prevention
An appeals operation that wins denials while the same denials keep arriving is an expensive way to stand still. The recovery work and the prevention work are different disciplines, and both have to be owned.
Not every denial is appealable, and not every appealable denial is recoverable.
Denial management is prevention, root-cause analysis, correction, appeal coordination, and the operating controls that keep the cause from returning. It is not a clearinghouse feature and it is not a report. Denial reporting alone does not establish ownership of the upstream causes outside billing.
Aava will say plainly which denials are worth pursuing and which were lost before the claim was created. A timely-filing denial is not a recovery opportunity. An eligibility denial where no coverage existed is not a recovery opportunity. Treating every denial as recoverable produces an appeals operation that consumes more than it returns, and a denial rate that never moves.
Categorised by what can actually be done about them.
Reason-code taxonomies are useful for reporting but insufficient for deciding what to do. The operational distinction is whether a denial is correctable, appealable on its merits, or preventable only.
Front-end eligibility failures
Coverage was not in force, the plan was not the one recorded, or the patient was not the subscriber. Potentially correctable if the true coverage is identified inside the filing window. Where no coverage existed, there is nothing to appeal — the outcome was fixed at intake.
Authorization failures
No authorization obtained, the wrong level of care authorized, or a continued-stay review that lapsed. The availability and scope of retrospective review vary by payer, plan, contract, and governing requirements.
Documentation and medical necessity
The record does not substantiate the level of care billed. This category may be appropriate for appeal when the record and applicable requirements support the challenge. It also warrants care before appealing reflexively, because the same record is what an audit would examine.
Coding and claim-format errors
Generally correctable. These can also be miscounted as denials when they were actually rejections that never entered adjudication—a distinction that can distort denial reporting.
Timely filing
Ordinarily terminal. Where the filing limit has passed and no exception applies, the claim is unpayable regardless of how appropriate, documented, or correctly coded the underlying care was. This category cannot be recovered; it can only be prevented.
Payer processing issues
Adjudication errors, configuration defects, and misapplied contract terms on the payer's side. Recoverable, but only by an organization keeping enough evidence to demonstrate the error — dated follow-up records, remittance history, and the contract itself.
Payment variance and underpayment
Not a denial at all. The claim paid, at the wrong amount. Invisible unless remittances are reconciled against contracted expectation rather than against billed charges, which is why this leak persists in organizations whose denial reporting looks healthy.
What Aava installs and runs.
Classify at the point of receipt
Every denial assigned a root cause before it is worked, by someone who is not incentivised only to overturn it. Classification after the fact is reconstruction, and it drifts toward whatever is easiest to defend.
Separate rejections from denials
Different queues, different owners, different measurement. A rejection never reached adjudication; counting the two together makes both numbers meaningless.
Route the cause upstream with a named owner
A denial category with no owning function outside billing is likely to recur. The routing is the intervention — the appeal is only the recovery.
Triage on merit, not on reflex
Appeal where the determination is substantively wrong and the record supports it. Correct and resubmit where the defect is technical. Write off, deliberately and with the cause recorded, where neither applies.
Track deadlines as operational obligations
Appeal windows differ by payer, plan, product, and determination type. They belong in a dated system with an owner, not in an adjudicator's memory.
Measure the trend that matters
Overturn rate measures the appeals team. Denial rate by root cause measures the organization. If overturns rise while root-cause volume holds steady, the operation is getting better at absorbing a problem it is not fixing.
Appeal rights are not one process. They depend on who the payer is.
The three regimes below are distinct. Confusing them creates avoidable cost in denial operations, because each has its own decision-maker, its own sequence, and its own deadlines. Nothing here describes any particular plan, any commercial payer generally, or any state programme. Confirm the process that applies to a given claim with the responsible payer or authority.
- Medicare fee-for-service (Parts A and B). Section 1869 of the Social Security Act and 42 CFR part 405 subpart I establish five levels of appeal: redetermination by a Medicare Administrative Contractor; reconsideration by a Qualified Independent Contractor; a decision by the Office of Medicare Hearings and Appeals; review by the Medicare Appeals Council; and judicial review in federal district court. CMS states that a party has 180 days from receipt of the redetermination decision to request reconsideration, and that the redetermination decision is presumed received five days after the date on the notice unless there is evidence to the contrary.
- ERISA-governed group health plans. Under 29 CFR 2560.503-1, an adverse benefit determination expressly includes a denial resulting from the application of utilization review, and a failure to cover an item or service because it was determined experimental, investigational, or not medically necessary or appropriate. Plans must give claimants at least 180 days to appeal, may not require more than two appeals before a civil action, and must have the appeal decided by a fiduciary who is neither the original decision-maker nor that person’s subordinate. Where the determination rests in whole or part on medical judgement, the plan must consult a health care professional with appropriate training and experience.
- Non-grandfathered group and individual coverage. 45 CFR 147.136 sets out internal claims and appeals and external review processes for coverage within its scope, including requirements drawn from the ERISA claims procedure regulation.
What Aava does — and what it does not.
- Aava can design, staff, operate, and hold accountability for the denial-management function, or oversee a vendor performing it.
- Aava is not a payer, a clearinghouse, or a utilization-management organization.
- Aava is not a coding authority and does not represent its work as authoritative coding advice.
- Aava is not a law firm and does not provide legal advice on appeal rights or coverage disputes.
- Aava does not make or overturn coverage, medical-necessity, or payment determinations — those belong to the payer, the plan, and the applicable review process.
- No appeal outcome, denial overturn, recovery amount, collection result, denial-rate reduction, or accounts-receivable result is guaranteed.
Go directly to the primary source.
Links to federal agencies and regulations are provided for reference and do not imply affiliation, authorization, endorsement, or approval.
- Original Medicare (Fee-for-Service) Appeals — the five levels of appeal — United States (Medicare Parts A and B)
- Second Level of Appeal: Reconsideration by a Qualified Independent Contractor — United States (Medicare Parts A and B)
- 29 CFR 2560.503-1 — Claims procedure (ERISA) — United States (ERISA-covered employee benefit plans)
- 45 CFR 147.136 — Internal claims and appeals and external review processes — United States (non-grandfathered group and individual coverage)
- 42 CFR 424.44 — Time limits for filing claims — United States (Medicare fee-for-service)
- Statement of the Departments of Labor, HHS, and the Treasury regarding enforcement of the 2024 MHPAEA Final Rule (May 15, 2025) — United States
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Last reviewed: · Next scheduled review: October 22, 2026
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