Most denial reports tell you what got denied. That's fine, but it doesn't tell you what to do about it. This engine goes further. It ingests EDI 835 remittance files across 16 practice types, loads claims into a SQLite database with CARC/RARC code intelligence, routes each denial to one of 12 destination categories based on CARC/RARC code logic, and auto-posts expected adjustments like CO-45 and PR-1/2/3 before they ever reach the denial queue.
The routing is based on ANSI X12 CARC/RARC code combinations mapped across 12 destination categories: Coding, Billing, Credentialing, Registration, Authorization, Documentation, Coordination of Benefits, Plan Limitation Review, Non-Covered Review, Duplicate Claim, Workers Comp / P&C, and Payer Follow-Up. CO-45 is handled by auto-post logic that splits Contractual Adjustments from Recoups based on balance. PR-1, PR-2, and PR-3 route automatically based on whether the most recent payment came from primary or secondary. The CPT Denial Intelligence module adds a second layer — 30+ high-denial-risk CPT codes analyzed with root causes, prevention strategies, and recovery routing built in.
The engine runs a three-layer assessment. First it excludes what's not recoverable. Then it evaluates the CARC/RARC relationship. Then it routes each denial to the right team with enough context to act on it.
Filter Patient Responsibility and Contractual Adjustments
Route Claims to Appropriate Team for Review (Small subset of exmaples provided.)
Provider not enrolled with payer — gaps in provider eligibility
Missing or invalid information — coding correction required
Exact or overlapping claim — review claim filing indicator before action
Focus on net recoverable revenue. Routing every denial to the right destination means your team spends their time on work that actually brings money back in.
Standard denial reports show you everything. That's the problem. You're looking at a mix of actionable denials, auto-post transactions, and contractual adjustments that have nothing to do with recovery. This engine separates them so your team only works what actually needs attention.
Handles auto-post transactions before they enter the denial queue. PR-1/2/3 route based on most recent payer payment: if primary paid, the claim holds for secondary; if secondary paid, the balance moves to patient responsibility. CO-45 posts as a Contractual Adjustment when the adjustment equals billed minus patient responsibility, or as a Recoups item when the adjustment amount is negative. Neither enters the denial queue.
Evaluates the relationship between the Claim Adjustment Reason Code and the Remittance Advice Remark Code to determine exactly what needs to happen. Routing destinations are mapped across 1,900+ CARC/RARC combinations, with every code assigned to one of 12 destinations based on the nature of the denial and the team best positioned to resolve it.
Goes beyond routing to analyze 30+ high-denial-risk CPT codes across E/M, TCM, CCM, RPM, AWV, Surgery, Radiology, Lab, PT, Behavioral Health, Cardiology, and Dermatology. Each CPT entry includes denial rates, root causes, and prevention strategies. The vw_CPT_Denial_Recovery_Intelligence and vw_High_Value_Recovery_Targets views surface this data for operational dashboards.