Denial Management / Denial Codes Tab

Allows the list of denial codes to be filtered by Level, Code, and/or Description.

Selecting an option from the Level drop down list will limit the denial codes displayed.

As you type in the Code and/or Description fields, the payers and plans in the list are filtered to show only those that match what is typed.

To restore the list to all payers and plans, clear the contents of the filters.

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(Pulled from created/updated Denial Management rules.)

The categorization of the denial code.

• System - System rules, generic or common for all.
• Practice - User-defined rule applicable to practices. Adjustment and denial rules are used as the default adjustment and denial rules for all payer and plans in the practice.
• Payer - User-defined rule applicable to payers. Adjustment and denial rules assigned to the payer override adjustment and denial rules at the practice, and are unique to that payer.
• Plan - User-defined rule applicable to plans. Adjustment and denial rules assigned to the plan override adjustment and denial rules at the payer and the practice, and are unique to that plan.

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(Pulled from created/updated Denial Management rules.)

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(Pulled from created/updated Denial Management rules.)

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(Pulled from created/updated Denial Management rules.)

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(Pulled from created/updated Denial Management rules.)

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(Pulled from created/updated Denial Management rules.)

The group and reason codes associated to the adjustment and denial rule for communicating from one payer to another why a claim was not paid as billed. For example, PR (Patient Responsibility) is a group code that can have a reason code of 1, indicating that the amount of the adjustment is due to a deductible requirement.

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(Pulled from created/updated Denial Management rules.)

The breakdown of the adjustment and denial rule for Primary and Non-Primary payments, including the selections for:

• Roll To
• Adjustment
• Writeoff

The adjustment and denial rule for rolling financial responsibility to the next party when the associated group and reason code is used in Connect Back Office. The Roll To options are defined as follows:

• Next Plan - The financial responsibility rolls to the next plan in line. For example, if the claim has a primary and a secondary payer and the primary payer adjusts or denies all or a portion of the claim, the financial responsibility will roll to the secondary payer. Note: If no secondary insurance exists, next plan rolls the balance to the guarantor.
• Guarantor - The financial responsibility rolls to the guarantor.
• Do Nothing - The financial responsibility remains as is and does not roll to another party.

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(Pulled from created/updated Denial Management rules.)

Indicates whether an adjustment is allowed.

• Allowed - An adjustment is allowed.
• Disallowed - An adjustment is not allowed.

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(Pulled from created/updated Denial Management rules.)

This option indicates whether a contractual writeoff is allowed for the adjustment and denial rule.

• Allowed - A writeoff is allowed.
• Disallowed - A writeoff is not allowed.

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(Pulled from created/updated Denial Management rules.)

The description of the rule level.

If the adjustment and denial rule is at the System level, it will list it as System.

If the adjustment and denial rule is at the Practice, Payer, or Plan level, it will list the practice(s), payer(s), or plan(s) to which it applies.

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(Pulled from created/updated Denial Management rules.)

The text that appears on the statement when the adjustment and denial rule is used in Connect Back Office. If not populated, the contents of the Name field is used.

This information is entered in the Statement Label option on the Denial Code window. 

Opens the Denial Code window where you can define user adjustment and denial rules for a practice, payer, or plan.

Opens the Denial Code window where you can modify a user adjustment and denial rule, or inactivate / add a statement label to a system adjustment and denial rule.

Deletes adjustment and denial rules from the master list. System adjustment and denial rules cannot be deleted.

Deleting Denial Management Rules