How do I work a denial without calling the payer?
Quick Answer
Start with the ERA/EOB, claim status, eligibility, payer policy, and portal tools. Many denials can be resolved through corrected claims, portal reconsiderations, secure messages, or appeals without a phone call. Call only when the information or action you need is unavailable electronically.
Step-by-Step Instructions
Read the ERA/EOB first
Identify the CARC and RARC codes, denied service line, allowed amount, payment, patient responsibility, and whether the issue is claim-level or line-level. The remittance often tells you the next action without a phone call.
Check claim status in the payer portal
Confirm whether the claim is finalized, pending, rejected, denied, partially paid, or already under review. Read any payer messages or claim notes before taking action.
Verify eligibility and benefits when relevant
For coverage, COB, termination, network, or benefit denials, verify eligibility for the exact date of service. Save evidence of active coverage or the correct payer order when it affects the resolution.
Check payer policy or coding requirements
For medical necessity, authorization, bundling, frequency, modifier, and non-covered denials, review the payer policy and the claim details before deciding whether to correct, appeal, or escalate to coding.
Use electronic resolution options
If available, use corrected claim submission, reconsideration, secure messaging, document upload, appeal, or claim inquiry through the payer portal. Save confirmation numbers and screenshots when needed for follow-up.
Escalate internally when the issue is not billing-owned
Send coding issues to coding, authorization issues to the authorization team, enrollment or pay-to provider issues to the appropriate billing/enrollment team, and medical necessity issues requiring clinical support to the correct reviewer.
Call only when electronic options cannot answer the question
A phone call is appropriate when the portal lacks the necessary detail, the claim is stuck beyond the stated timeframe, the payer requests a call, or you need a manual action that cannot be completed electronically.
Common Mistakes to Avoid
Calling before reading the ERA/EOB and portal claim status.
Resubmitting a claim that is still pending.
Treating every denial as an appeal instead of checking whether a correction is needed.
Failing to document portal reference numbers and submission dates.
Ignoring coding, enrollment, or authorization ownership and trying to fix a non-billing issue alone.