Manage denials and appeals

Outcome

Denials are reviewed, categorized, appealed (where appropriate), and resolved within their deadlines. CARC/RARC codes that lack a category get mapped so future denials are auto-categorized.

Prerequisites

• denials.read to browse, denials.update to change status or file appeals.
• For auto-correction: see Auto-correction operator playbook and Manual auto-correction trigger.

Daily workflow

Steps

1. View open denials in the Denials workspace, or via API:

   curl "http://localhost:3010/denials?status=OPEN"

2. Review auto-categorization. When an 835 posts with denial CARC/RARC codes, the denial service maps them via billing.denial_category_mapping:

   SELECT carc_code, rarc_code, denial_category,
          is_correctable, default_correction_strategy
   FROM billing.denial_category_mapping
   ORDER BY carc_code;

3. Add a new CARC/RARC mapping when the service surfaces a code without a category. This makes the next denial of the same kind auto-correct.

   INSERT INTO billing.denial_category_mapping (
     carc_code, rarc_code, denial_category,
     is_correctable, default_correction_strategy, description
   ) VALUES (
     'CO', '109', 'AUTH_MISSING', true, 'CORRECT_AND_RESUBMIT',
     'Claim not covered by this payer - missing authorization'
   );

   Column	Meaning
   denial_category	High-level bucket (AUTH_MISSING, TIMELY_FILING, DUPLICATE, BUNDLING, PATIENT_LIABILITY, …).
   is_correctable	If true, denial is eligible for the auto-correction engine.
   default_correction_strategy	CORRECT_AND_RESUBMIT, APPEAL, WRITE_OFF, PATIENT_RESPONSIBILITY.

4. File an appeal when correction isn't possible but the determination is contestable:

   curl -X POST http://localhost:3010/denials/<denial_id>/appeals \
     -H "Content-Type: application/json" \
     -d '{
       "appealLevel": 1,
       "submissionMethod": "PORTAL",
       "deadline": "2026-06-15",
       "notes": "Authorization was in place at time of service"
     }'

5. Monitor appeal deadlines weekly:

   SELECT dr.denial_id, dr.claim_id, dr.denial_category,
          dr.appeal_deadline,
          dr.appeal_deadline - CURRENT_DATE AS days_remaining
   FROM billing.denial_record dr
   WHERE dr.status IN ('OPEN', 'IN_REVIEW', 'APPEALING')
     AND dr.appeal_deadline IS NOT NULL
     AND dr.appeal_deadline - CURRENT_DATE <= 14
   ORDER BY dr.appeal_deadline;

6. Resolve a denial once it's worked:

   curl -X POST http://localhost:3010/denials/<denial_id>/resolve \
     -H "Content-Type: application/json" \
     -d '{
       "resolution": "CORRECTED",
       "resolvedBy": "billing_team",
       "resolutionNotes": "Corrected and resubmitted as claim <new_claim_id>"
     }'

Validation

Check	Expected
billing.denial_record.status	Advanced past OPEN
New mappings cover the surfaced CARCs	Auto-categorization fires next time
Appeal records have deadline set	Weekly query finds none past due

Troubleshooting

Symptom	Cause	Fix
Denial stays OPEN despite resolve attempt	Wrong actor or scope	Verify denials.update scope on the JWT.
Auto-correction didn't fire	CARC missing from denial_category_mapping or is_correctable=false	Add/update mapping; replay denial via manual trigger.
Appeal deadline missed	Tracking not run for > 7 days	Check ops cadence; consider scheduled report (see Scheduled email).

Cross-references

• Auto-correction operator playbook — full handler coverage, idempotency, dashboards.
• Manual auto-correction trigger — re-running a handler after upstream context changed.
• COB tertiary waterfall — for denials that should escalate to the next-priority payer.

Next

3.3 — COB adjustment snapshot ops