The Denial Management page is used to manage the adjustment and denial rules used in Back Office.
The Connect platform includes both system and user-defined rules. These rules represent the adjustment reason and denial codes used by payers to inform other payers why a claim was not paid the way it was billed. Payers use adjustment reasons or denial codes on the Explanation of Benefits (EOB). The adjustment reason or denial codes are specific to electronic claim filing and are essential to the payment entry function for processing secondary claims correctly.
The adjustment and denial rules determine the behavior of the HIPAA-compliant group and reason codes used in Back Office to explain from one payer to another why a claim was adjusted or denied and the action that was taken as either an adjustment or contractual writeoff.
By default, a system adjustment and denial rule has a prefix of RC (Remark Code), for example, RC-1 = Deductible Amount and is assigned to the practice. The default set of adjustment and denial rules cannot be changed, but can be inactivated or given a label that is printed on statements. For example, RC-1 is the adjustment and denial rule for the deductible amount and is associated to group and reason codes, CO-1, PR-1, PI-1, CR-1, and OA-1. You can add a statement label so that specific text is printed on your statements associated with this reason code, for example, Applied to Deductible.
User adjustment and denial rules are the rules that are unique to your practice for handling the behavior of the HIPAA-compliant group and reason codes. These rules can be defined explicitly for a practice, payer, or plan. Adjustment and denial rules are assigned hierarchically by practice, payer, or plan. Payer and plan rules override rules at the practice, and the rules at the plan overrides the rules at the payer. The user-defined rules are added to your Connect platform through the Denial Code page.