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Documentation Index

Fetch the complete documentation index at: https://help.elationhealth.com/llms.txt

Use this file to discover all available pages before exploring further.

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Overview

A denial is a claim that the payer adjudicated and chose not to pay (i.e. paid at $0). A denial is different from:
  • Rejection — the claim never reached the payer for adjudication because of a front-end edit at the clearinghouse or payer. Fix the issue and resend the claim to the clearinghouse.
  • Underpayment — the claim was paid, but for less than expected. Post the payment if you agree to the decision or file an appeal using Claim Appeals.
  • Recoupment — the payer takes back a previously posted payment, often via a future ERA. Use Posting Voided, Reversed, or Updated Payments to correct the payment or or file an appeal using Claim Appeals.
  • Contractual write-off (CO45) — not a denial; the payer paid the contracted amount and the difference from billed is written off - this can typically be posted unless the contracted amount does not match your contract terms.
Working denials promptly protects revenue, keeps A/R aging healthy, and avoids missing timely-filing limits.

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Before you begin

  • Have the EOB or ERA in front of you, with the CARC (Claim Adjustment Reason Code) and RARC (Remittance Advice Remark Code) for each denied line.
  • Know the payer’s timely-filing and timely-appeal limits.

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Glossary

  • CARC (Claim Adjustment Reason Code) — explains why an adjustment was made (e.g., CO29 timely filing, CO50 non-covered, PR1 deductible).
  • RARC (Remittance Advice Remark Code) — supplemental detail (e.g., MA01 appeal rights, N115 LCD denial).
  • Group code — prefix on a CARC indicating who is responsible:
    • CO Contractual obligation (provider write-off)
    • PR Patient responsibility
    • OA Other adjustment
    • PI Payer initiated
  • Partial denial — some lines on a claim paid, others denied.
  • See Common Code Denials for a reference list of common denial codes and their typical resolution paths.

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End-to-end workflow

1

Find the denial

Denials typically surface in the ERA review queue, the Claims tab, and on the A/R aging report.
2

Read the codes

Identify the CARC, RARC, and group code on each affected line.
3

Categorize the issue

For guidance on resolving specific denial codes, take a look at our Common Code Denials article.
4

Research the root cause

Common categories: eligibility, coding, authorization, demographics, COB, timely filing, medical necessity.
5

Post the denial

Record a $0 payment with the adjustment code(s) to capture the denial in financials and route the balance while you work on a resolution.
6

Document your work for easy follow up

Add a Claim Note and Payment Note with date, payer, code, action, and follow-up details.
  • Use a consistent Note format on every worked denial so the audit trail is searchable and reportable:
[Date] [Payer ref / EOB #] - Denied CARC [code] [RARC if any]: [reason].
Action: [resubmit / corrected claim / appeal / write off / transfer to patient].
Follow-up by: [date].
7

Action on the denial

Take the necessary action needed for the denial. Common actions include:
  • Resubmit the claim after correcting issues.
  • Appeal the denial if no issues were identified.
  • Write off the balance if you missed the appeal deadline or a resolution cannot be reached.
  • Transfer the balance to the patient if appropriate.
8

Verify and track your work

Confirm the claim’s new status and set a follow-up date.

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Decision matrix

For a side-by-side mapping of denial type → common CARCs → typical action, plus a fuller reference list of certain codes and their resolutions, see Common Code Denials.

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Step-by-step articles

Use these articles for the tactical work as needed:

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Special cases

  • Partial denial (some lines paid, some denied) — work each denied line independently. Record the paid lines normally and post a $0 with adjustment on the denied lines. If you disagree with the denial, file an appeal using Claim Appeals.
  • Recouped claim (offset on a future ERA) — typically handled as a reversal against the original payment. See Posting Voided, Reversed, or Updated Payments. If you disagree with the recoupment, file an appeal using Claim Appeals.
  • Patient already paid the transferred balance — the claim may now have a credit. See Manage patient credits and overpayments.
  • Capitation denial — capitation claims are settled, not paid; see Posting a Capitation Payment.
  • Front-end rejection (clearinghouse, not payer) — the claim never reached the payer for adjudication; correct the issue and resubmit. See Claims Queue.
  • Crossover denial (Medicare to Medicaid) — confirm the crossover indicator on the original claim before resubmitting to the secondary payer directly.
  • Bulk denials from one payer — likely a payer system issue or contract issue. Reach out to the payer for clarification before reworking individual claims.

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Preventing denials

Denials are cheaper to prevent than to work. Front-load these checks:
  • Verify eligibility at scheduling and check-in.
  • Track prior authorizations and referrals before service.
  • Review coding before claim submission.
  • Keep provider credentialing current with each payer.
  • Use the claim scrubber to catch front-end errors. See AI Billing Guide: Scrubbing claims.

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Verifying your work

After working a denial, confirm:
  • The claim’s status reflects the action (Resubmit, In Appeal, Settled, or Patient).
  • A Claim Note records what was done and the follow-up date.
  • The denial appears in Denials Reporting so it counts toward your denial-rate KPIs.
  • Claim History shows the full audit trail. See Claim History.