Denied claims recovery

Find your appealable denials. Get the packets ready to send.

When a payer denies a claim, they include a reason code. Many of those codes have established reversal pathways — but identifying which specific denied claims are worth appealing, and in what order, is work that falls through the cracks in most billing teams.

MedicalRouter reads your ERA and EOB files, classifies each denial by CARC code, identifies which are appealable, and generates a ready-to-send appeal packet for each one — ranked by recoverable dollar amount.

No long-term contract · 25% success fee on recovered dollars only · Learn more about the product →

What a denial finding looks like

Illustrative example. Output structure matches what the engine produces from real ERA files.

DenialAppeal ready

Claim 2024-03851 · Cigna · DOS 2024-09-14

$2,100

net recoverable

Billed

$2,100

Paid

$0

Denial reason

CO-50

Category

Medical necessity

Denial explanation

Payer determined service was not medically necessary. Appeal with clinical documentation and supporting physician notes. Draft letter included in packet.

Appeal packet ready to download

Letter · Claim detail · Math trace

Denial categories the engine identifies

Each category has a distinct reversal pathway. The engine generates a specific appeal letter template for each type — not a generic letter.

CO-50Medical necessity

Payer deemed service not medically necessary. Typically appealable with clinical documentation and supporting notes.

CO-29Timely filing

Filing deadline passed per payer rules. Appealable when proof of prior timely submission exists — e.g., a clearinghouse confirmation.

CO-97Bundling

Payer bundled payment into another service. Often appealable with modifier 59 or XE to establish distinct procedure.

CO-4Modifier issue

Procedure code inconsistent with modifier used, or modifier missing. Correct the modifier and resubmit.

CO-16Missing information

Claim has a billing error or is missing required information. Submit the missing item; typically straightforward to resolve.

CO-39Prior authorization

Service denied at authorization. Appealable with clinical documentation supporting medical necessity.

Some denial codes are non-appealable — CO-18 (duplicate), CO-27 (post-termination), CO-119 (benefit maximum). The engine flags these separately so your team does not spend time on claims that cannot be recovered.

From ERA file to appeal packet

  1. 1

    Upload your 835 ERA or EOB files

    Files from UHC, Cigna, Aetna, BCBS, Medicare, and other major payers are supported. Upload once per batch — typically monthly or after each remittance cycle.

  2. 2

    Each denial is classified by CARC code

    The engine reads each claim-level denial reason code, looks it up against the rule set, and determines whether a reversal pathway exists. Appealable and non-appealable denials are separated.

  3. 3

    Findings are ranked by recoverable amount

    Appealable denials are ranked by net recoverable dollar amount so your billing team works highest-value cases first. Each finding shows the claim detail, the reason code, and the math.

  4. 4

    Download the appeal packet and send

    Each appealable denial has a packet: a denial-specific draft letter, the claim summary, and supporting documentation guidance. You review, edit if needed, and send to the payer.

Who this is for

  • Independent specialty practices — cardiology, orthopedics, oncology, and multi-specialty groups
  • 1–10 providers billing commercial payers and Medicare
  • Billing teams that receive denial EOBs but do not have a systematic process for identifying which ones to appeal
  • Practices processing 50+ claims per month with a meaningful denial rate
  • Teams that want a ranked, prioritized list — not a pile of raw remittance data
Not a fit: large hospital systems with dedicated denial management departments, RCM vendors, or practices processing fewer than 50 claims per month.

30-day pilot pricing

$500

flat onboarding fee, one-time

+ 25% success fee

on net recovered payer dollars only

  • Full denial analysis from your 835 ERA and EOB files
  • Appealable vs. non-appealable classification by CARC code
  • Ready-to-send appeal packets with denial-specific letter templates
  • No per-claim fees. No per-payer fees. No long-term contract.
The honest framing:If your files contain no appealable denials, you are out $500. The 25% success fee applies only to payer dollars that are actually recovered — not patient responsibility, not the setup fee.

By starting the pilot you agree to the Pilot Services Agreement, including the non-refundable $500 setup fee and the 25% success fee terms.

Questions about denied claims recovery

More questions? Full FAQ or contact us.

Start recovering denied claims revenue

Upload your ERA or EOB files. Get a ranked list of appealable denials with ready-to-send packets. Pay 25% only on what is actually recovered.