Claim denial control tower

DENIAL CTRL · WS-04│USR OPS-LEAD│SHIFT 04:30 → 16:30 CT│● LIVE FEED4/30/2026, 2:22:00 PM
$ AT RISK
$608.4K
▼ -8.4%
OPEN DEN.
169
▼ -12
AVG AGE
94D
▼ -2D
RECOV %
26.8%
▲ +4.1pp
◆ ROOT CAUSE · $
ELIGIBILITY$221.9K
CODING$175.8K
DOCUMENTATION$136.1K
AUTH$81.7K
TIMELY FILING$49.8K
COB$45.9K
BUNDLING$43.5K
◆ AGING · OPEN $
0-30   $79.7K
31-60  $107.3K
61-90  $97.8K
91-120 $100.6K
120+   $223.1K
◆ 14D TREND · $
Denial trendT-14T-0
ALERT > SPIKE T-6 · UHC AUTH POLICY CHG
WORKLIST│218 ROWS · 47 ERAS · 835 TXN
CPT/ICDCARC/RARCSTATUSOWNER
DN-10256ANNELIESE CROWFOOT
BCBS ILLINOIS · PPO
93000/I10CO-29$650.89179DWRITTEN OFFMARCUS BEALE
DN-10331BRYANT MOKOENA
AETNA · HMO
99396/Z00.00CO-96 / N425$1889.78179DAPPEALINGCAMILA ORTIZ
DN-10299THEO VANDERMEER
KAISER · HMO
20610/M17.11CO-16 / M51$264.17177DAPPEALINGUNASSIGNED
DN-10402INES VANDERMEER
CIGNA · OAP
97110/M25.561CO-97$1024.12177DRESOLVEDYUSUF HALIM
DN-10417CAMILA Ó BRIAIN
BCBS TEXAS · HMO
20610/M17.11CO-97$5804.50177DAPPEALINGYUSUF HALIM
DN-10242BRYANT BERTOLINI
CIGNA · OAP
45378/Z12.11PR-1$5398.94175DIN REVIEWPRIYA ANAND
DN-10311AIYANA ORTIZ
UNITEDHEALTHCARE · CHOICE PLUS
77067/Z12.31CO-96 / N425$2730.57175DWRITTEN OFFCAMILA ORTIZ
DN-10235IDRIS NAKAGAWA
MEDICAID · MOLINA
99396/Z00.00CO-29$6332.28174DIN REVIEWPRIYA ANAND
DN-10287NALEDI CHAMBERLAIN
AETNA · PPO
45378/Z12.11CO-18$4205.18174DOPENCAMILA ORTIZ
DN-10288CAMILA CROWFOOT
MEDICAID · MOLINA
71046/J20.9CO-18$4591.73174DAPPEALINGUNASSIGNED
DN-10312REGINALD ANAND
HUMANA · GOLD PLUS
11102/D22.5CO-197 / N210$1431.11172DOPENUNASSIGNED
DN-10333SOREN HOLLOWAY
MEDICAID · CENTENE
45378/Z12.11CO-109$2402.28172DAPPEALINGPRIYA ANAND
DN-10405DASHIELL SALGADO
TRICARE · PRIME
77067/Z12.31CO-11$1029.46172DIN REVIEWPRIYA ANAND
DN-10217MARCUS BEAUFORT
KAISER · HMO
80053/E11.9CO-45$5332.69171DOPENMARCUS BEALE
DN-10245TOMÁS BRUBAKER
AETNA · HMO
99214/J45.41CO-18$2077.73169DOPENCAMILA ORTIZ
DN-10292SOREN ANAND
CIGNA · LOCALPLUS
77067/Z12.31CO-45$2426.62169DOPENUNASSIGNED
DN-10362CAMILA PETROV
TRICARE · PRIME
99396/Z00.00CO-109$4308.58169DWRITTEN OFFPRIYA ANAND
DN-10377DEVON PETROV
MEDICAID · MOLINA
93000/I10CO-18$5343.88169DAPPEALINGYUSUF HALIM
DN-10243YUSUF ORTIZ
UNITEDHEALTHCARE · CHOICE PLUS
99214/J45.41PR-1$2537.65166DOPENUNASSIGNED
DN-10390HIROSHI CHAMBERLAIN
TRICARE · PRIME
99213/M54.5CO-18$4489.42166DOPENCAMILA ORTIZ
DN-10408PILAR Ó BRIAIN
MEDICARE · PART B
99213/M54.5CO-11$1396.83166DIN REVIEWYUSUF HALIM
DN-10238CALEB CASTELLANOS
UNITEDHEALTHCARE · CHOICE PLUS
43239/K21.9CO-109$4821.26165DAPPEALINGPRIYA ANAND
DN-10328PRIYA SUNDARAM
HUMANA · GOLD PLUS
97110/M25.561CO-22$6386.29163DAPPEALINGMARCUS BEALE
DN-10378OCTAVIO OKAFOR
CIGNA · LOCALPLUS
99214/J45.41CO-11$2890.10163DRESOLVEDPRIYA ANAND
DN-10264ANNELIESE HOLLOWAY
CIGNA · OAP
99213/M54.5CO-97$6310.80162DOPENYUSUF HALIM
1-25 / 218
DN-10200 │ NALEDI YAMAMOTO │ MEDICAID CENTENE · DOS 2025-12-25 · $4132.40 BIL / $1764.37 ALW · CO-96 / N425
REASON > NON-COVERED CHARGE
● AI APPEAL DRAFT
Re: DN-10200

We are appealing the denial of claim CLM-883214 for Naledi Yamamoto (MRN-739231). Based on payer policy and chart documentation, the service rendered on 2025-12-25 (CPT 99396, ICD-10 Z00.00) satisfies medical-necessity criteria. Supporting documents are attached: clinical note, prior authorization record, and applicable LCD/NCD reference.

Requested action: reprocess and remit per contracted rate.TONE=PROFESSIONAL · CITATIONS=2360 CH
● CLAIM META
CLAIMCLM-883214MRNMRN-739231ROOTDOCUMENTATIONOWNERCAMILA ORTIZALLOWED$1764.37VAR$2368.03● ATTACHMENTS
[+] ENCOUNTER NOTE · 2025-12-25 · 4P
[+] PRIOR AUTH · PA-44219.PDF
[+] PAYER LCD/NCD · CPT 99396
[+] 835 ERA · CLP/CAS DETAIL
NOTE > AWAITING PAYER RESPONSE ON APPEAL LETTER SENT 2026-04-18.
F1 HELP · F2 FILTER · F5 REFRESH · CTRL+E EXPORT● CONNECTED · LATENCY 42MS

		CPT/ICD	CARC/RARC			STATUS	OWNER
DN-10256	ANNELIESE CROWFOOT BCBS ILLINOIS · PPO	93000/I10	CO-29	$650.89	179D	WRITTEN OFF	MARCUS BEALE
DN-10331	BRYANT MOKOENA AETNA · HMO	99396/Z00.00	CO-96 / N425	$1889.78	179D	APPEALING	CAMILA ORTIZ
DN-10299	THEO VANDERMEER KAISER · HMO	20610/M17.11	CO-16 / M51	$264.17	177D	APPEALING	UNASSIGNED
DN-10402	INES VANDERMEER CIGNA · OAP	97110/M25.561	CO-97	$1024.12	177D	RESOLVED	YUSUF HALIM
DN-10417	CAMILA Ó BRIAIN BCBS TEXAS · HMO	20610/M17.11	CO-97	$5804.50	177D	APPEALING	YUSUF HALIM
DN-10242	BRYANT BERTOLINI CIGNA · OAP	45378/Z12.11	PR-1	$5398.94	175D	IN REVIEW	PRIYA ANAND
DN-10311	AIYANA ORTIZ UNITEDHEALTHCARE · CHOICE PLUS	77067/Z12.31	CO-96 / N425	$2730.57	175D	WRITTEN OFF	CAMILA ORTIZ
DN-10235	IDRIS NAKAGAWA MEDICAID · MOLINA	99396/Z00.00	CO-29	$6332.28	174D	IN REVIEW	PRIYA ANAND
DN-10287	NALEDI CHAMBERLAIN AETNA · PPO	45378/Z12.11	CO-18	$4205.18	174D	OPEN	CAMILA ORTIZ
DN-10288	CAMILA CROWFOOT MEDICAID · MOLINA	71046/J20.9	CO-18	$4591.73	174D	APPEALING	UNASSIGNED
DN-10312	REGINALD ANAND HUMANA · GOLD PLUS	11102/D22.5	CO-197 / N210	$1431.11	172D	OPEN	UNASSIGNED
DN-10333	SOREN HOLLOWAY MEDICAID · CENTENE	45378/Z12.11	CO-109	$2402.28	172D	APPEALING	PRIYA ANAND
DN-10405	DASHIELL SALGADO TRICARE · PRIME	77067/Z12.31	CO-11	$1029.46	172D	IN REVIEW	PRIYA ANAND
DN-10217	MARCUS BEAUFORT KAISER · HMO	80053/E11.9	CO-45	$5332.69	171D	OPEN	MARCUS BEALE
DN-10245	TOMÁS BRUBAKER AETNA · HMO	99214/J45.41	CO-18	$2077.73	169D	OPEN	CAMILA ORTIZ
DN-10292	SOREN ANAND CIGNA · LOCALPLUS	77067/Z12.31	CO-45	$2426.62	169D	OPEN	UNASSIGNED
DN-10362	CAMILA PETROV TRICARE · PRIME	99396/Z00.00	CO-109	$4308.58	169D	WRITTEN OFF	PRIYA ANAND
DN-10377	DEVON PETROV MEDICAID · MOLINA	93000/I10	CO-18	$5343.88	169D	APPEALING	YUSUF HALIM
DN-10243	YUSUF ORTIZ UNITEDHEALTHCARE · CHOICE PLUS	99214/J45.41	PR-1	$2537.65	166D	OPEN	UNASSIGNED
DN-10390	HIROSHI CHAMBERLAIN TRICARE · PRIME	99213/M54.5	CO-18	$4489.42	166D	OPEN	CAMILA ORTIZ
DN-10408	PILAR Ó BRIAIN MEDICARE · PART B	99213/M54.5	CO-11	$1396.83	166D	IN REVIEW	YUSUF HALIM
DN-10238	CALEB CASTELLANOS UNITEDHEALTHCARE · CHOICE PLUS	43239/K21.9	CO-109	$4821.26	165D	APPEALING	PRIYA ANAND
DN-10328	PRIYA SUNDARAM HUMANA · GOLD PLUS	97110/M25.561	CO-22	$6386.29	163D	APPEALING	MARCUS BEALE
DN-10378	OCTAVIO OKAFOR CIGNA · LOCALPLUS	99214/J45.41	CO-11	$2890.10	163D	RESOLVED	PRIYA ANAND
DN-10264	ANNELIESE HOLLOWAY CIGNA · OAP	99213/M54.5	CO-97	$6310.80	162D	OPEN	YUSUF HALIM

RCM · Director of revenue cycle

Denials, root causes & appeal yield

What's denying, why, and how much we're recovering through auto-appeals.

Synthetic data

CARC breakdown

Top reason codes

CO-16 Lacks information
412
CO-97 Bundled / not separately payable
318
CO-50 Not medically necessary
244
PR-204 Service not covered
188
CO-29 Time limit expired
142

Denial $ by payer

UnitedHealthcare$412k

Aetna$284k

BCBS$221k

Cigna$168k

Medicare$125k

Appeal SLA

Avg days to draft appeal: 4.8d (down from 8.2d).

Connectors used

Eligibility & Claims

required

Stedi / Availity

Re-verify benefits before appeal

Microsoft Excel

required

Worklist exports for biller follow-up

Stripe

optional

Reconcile patient-responsibility shifts

Snowflake / BigQuery / Databricks

optional

Denial trend analytics