Denials Management Automation
We find denied claims, capture the payer's reason, and gather the information needed for the next step. The automation handles agreed corrections or prepares reconsideration and appeal documents. Your team reviews cases that need coding or clinical judgment.
Illustration of a denial run. Three denied claims enter the queue. For the first, the automation reads the payer message, matches it to the record, gathers the requested document and submits a reconsideration. For the second, it submits a corrected claim through a different, agreed route. The third is a medical-necessity denial, so it goes to staff with the payer message and documents. The example ends with 2 requests submitted and 1 needing clinical review. Both submitted cases stay open.
How PathGroup automated recurring denial work
PathGroup's team cross-checked records between athenahealth and its PathSys lab system. We built a data exchange and automation for recurring denial types. It gathers the available corrections, updates claims, and resubmits supported cases. Complex cases go to staff.
Measured results
Results from the targeted workflows and supporting automations at PathGroup. Resubmission is separate from a payer's decision.
A California medtech company cleared 80% of a 3,000-claim denial backlog in three weeks using automated reconsiderations. Read the medtech case study
The tasks behind a denied claim.
A denied claim needs a reason, supporting information, and the right next step. These are the tasks we automate.
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01Find
Bring the denied claim and its records together.
- Pick up denied claims from your billing queues, remittance files, or payer portals.
- Match each claim to the patient, service, and payer record.
- Pull the related documents and previous submission details.
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02Classify
Record the reason and the work it needs.
- Capture the payer's message and reason codes when provided.
- Group recurring issues using rules agreed with your team.
- Record the required next step and applicable deadline where confirmed.
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03Prepare
Prepare the response supported by your records.
- Apply agreed administrative corrections using verified source information.
- Gather the documents for a reconsideration or appeal.
- Send coding questions, clinical disputes, and incomplete cases to staff.
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04Follow up
Send supported responses and track what happens next.
- Submit supported corrections and reviewed requests through the right payer route.
- Save submission references, documents, and timestamps in your system.
- Check for updates and send unanswered or unresolved cases to staff.
We set up the workflow for the denial types you handle often. Your team reviews unfamiliar cases and decisions that need a person.
A corrected claim, reconsideration, and appeal follow different payer processes. Automation does not guarantee that a denial will be overturned or a claim paid.
Denials automation usually pays off when most of these are true.
- Your team sees the same denial reasons repeatedly.
- Staff gather records and re-enter corrections across several systems.
- Open denials wait for document uploads, resubmission, or status checks.
- You have clear handling rules for common cases and a review process for the rest.
What affects your savings
- How many denials you handle each month
- How long gathering records and preparing responses take by hand
- How many cases follow repeatable, supported correction rules
- Which payer routes and filing deadlines apply
- What it costs to build and maintain
The return is different for every organization. Schedule a call and we'll give you a quick, honest estimate of whether it's worth it for yours.
Schedule a callThe automation connects denial queues, supporting records, and payer responses.
Your staff keep using the systems they know. We use direct connections where available, or UiPath and Python for billing systems and payer portals. AI can read payer letters and supporting documents. Your team reviews uncertain matches, clinical disputes, and cases outside the agreed rules.
Example of the automation between three places. For the first denied claim, it gathers the visit note from the EHR, submits a reconsideration in the payer portal and saves the receipt in the billing system. For the second, it submits a corrected claim through a separate route and saves the reference. The third is a medical-necessity dispute, so it goes to the staff review queue with its documents. Later, a payer update shows the first case under review, and it stays open with a next-check date.
Monitored and maintained by us. We check the runs and update the workflow when payer processes or your systems change.
Rejected claims that never reached payer review are handled separately from denied claims. Coding decisions and clinical appeal arguments stay with the appropriate staff.
Patient data (PHI)
What happens to your patient data
Your data is safe.
- Where it runs
- On a machine you own: usually a virtual machine on your side, or your own AWS or Azure account.
- What we store
- We don't store patient data. The automation reads it, uses it and writes the result back. In the rare case PHI has to be in transaction data, it's encrypted.
- Who can access it
- Only the developer who builds and maintains the automation. On your machine, you decide who else gets access.
- What we sign
- A BAA before we see any patient data. AI runs on AWS, Azure or Google under BAAs, and your data isn't used to train models.
Is automating your denial work worth it?
Book a 30-minute call with Karl, our CTO. If you'd rather write, send us a message.
Walk me through the denials your team handles most often. Within the first 15 minutes, we can usually tell whether automation makes sense. We'll discuss the work involved and what we'd need to estimate the cost.
Karl