We know exactly how UHC, Aetna, BCBS, Cigna, Medicare, and Medicaid deny your claims. That knowledge is what separates One O Seven RCM’s 87% overturn rate from the 50% industry average in claim denial management services.
Payers don’t deny your claims randomly. They deny them systematically, using criteria you’re not supposed to know, through workflows designed to say no faster than you can respond. Your revenue isn’t disappearing because of mistakes. It’s disappearing because the system is built to keep it.
Most medical billing denial management companies respond to that system with the same generic template letter they’ve sent to every payer for the last five years. That’s not a strategy. It’s a surrender dressed up as a service.
One O Seven is different. We’ve mapped how every major payer denies, which criteria they apply, which codes they flag, and which documentation gaps they exploit. That intelligence is built into every appeal we file. It’s what makes recovery possible when generalist approaches fail.
Your denied claims aren’t a billing problem. They’re a payer-intelligence problem. We’ve solved it.
Every payer denies differently. Select yours below and see exactly what we know about how they deny, and exactly what we do to overturn it.
UHC processes more claims than any other commercial payer in the country. That volume is exactly why their denial system is so aggressive. UnitedHealthcare claim denial patterns concentrate heavily around medical necessity, and every medical necessity determination runs through InterQual criteria. Not general clinical guidelines. Not your physician’s notes alone. InterQual, by chapter and version.
An appeal that doesn’t cite the correct InterQual chapter fails before a reviewer reads the second sentence. That’s not a guess. That’s how UHC’s internal review process is structured.
We build every UHC appeal around InterQual criteria, not a generic template.
Here’s the issue with Aetna claim denial management that most billing teams don’t catch until it’s too late. Aetna’s Clinical Policy Bulletins update on a quarterly cycle. A CPB that governed your procedure in January may have changed by April. Practices submitting against the old version get denied, and they don’t always know why.
We monitor Aetna CPB updates automatically. Every appeal references the bulletin version in effect on the actual date of service, not the version your team happened to have saved. That single alignment shift changes outcomes on clinical denials that generic appeal letters consistently lose.
Most Blue Cross Blue Shield denial appeals fail because the practice’s billing team treated BCBS as a single national payer. It isn’t. BCBS is a federation of 36 independent plans, each with its own medical policies, prior authorization lists, and coverage rules. A BCBS Texas denial requires a completely different appeal than the same denial from BCBS California.
We maintain plan-level BCBS policy mapping across every state we bill into. When a denial comes in, we pull the specific plan’s current policy, not the brand’s general guidelines.
We appeal to the plan, not to the brand.
Cigna denial management services require a different knowledge base than UHC or Aetna appeals. Cigna doesn’t rely on InterQual for medical necessity determinations across its book of business. It runs its own proprietary coverage policy library, updated on its own schedule. An appeal that references InterQual against a Cigna denial is citing the wrong criteria system entirely.
Behavioral health is where Cigna denials concentrate most heavily. Level-of-care disputes, authorization complexity, and documentation requirements specific to Cigna’s own standards create a denial pattern that generic appeal templates consistently fail to address.
What usually happens is that the internal appeal gets denied and the claim gets written off. We don’t stop there. External appeal through an Independent Review Organization is a legitimate pathway, and we pursue it when Cigna’s internal process is exhausted.
Original Medicare denial management and Medicare Advantage denial management are two separate processes that require two separate workflows. Most billing companies conflate them. That conflation costs providers on both sides.
Original Medicare operates on Local Coverage Determinations and National Coverage Determinations. Every clinical denial traces back to a specific LCD or NCD. An appeal that doesn’t cite the correct determination by number and effective date is starting from the wrong position.
Medicare Advantage is different. MA plans set their own medical necessity criteria within CMS guidelines, and they deny at rates that frequently approach double what original Medicare produces. MA appeals follow a 60-day window with specific Independent Review Organization escalation rights that most providers never use because most billing companies don’t know to pursue them.
We manage the full MA appeal pathway. When the plan-level appeal fails, IRO escalation is the next step. We take it.
Medicaid managed care denial management is genuinely more complex than most billing teams realize. It’s not just Medicaid rules. Every MCO layers its own prior authorization requirements, coverage criteria, and appeal timelines on top of the state Medicaid baseline. A denial from a Texas MCO requires a completely different response than the same denial from a California MCO.
Retroactive authorization is one of the most underused recovery tools in this space. When a service was rendered before authorization was confirmed, many practices assume the denial is final. It often isn’t. Retroactive authorization requests are eligible in specific circumstances, and we pursue them on every applicable claim before writing anything off.
Medicaid managed care denial management done right means knowing your specific MCO, not just the state program. We know your MCO. We know their deadlines. We know what it takes to win.
Most billing companies react to denials after they land. PACT is built around how payers make their denial decisions, so we intercept problems before they stick and overturn them when they do.
Every claim is monitored from submission to payment. Denials are flagged within hours of payer adjudication and sorted by payer, reason code, dollar value, and appeal deadline automatically. High-priority denials near timely filing windows get escalated immediately. You get full real-time visibility into your denial inventory broken down by payer, not just in aggregate.
First-level, second-level, and third-level appeals are managed through final resolution as part of our denial appeal management services. External appeals are filed with Independent Review Organizations when internal pathways are exhausted. ALJ hearing support is provided for Medicare denials. Peer-to-peer review is coordinated for clinical disputes. Every appeal is built to that specific payer's requirements.
AAPC and AHIMA certified coders review every coding denial for ICD-10, CPT, and HCPCS accuracy. Modifier errors are corrected and resubmitted within 48 hours. A payer-specific coding edit library is applied before every claim leaves your system. Our coding denial management services ensure denials never sit waiting for bandwidth. They get worked the same day they are identified.
CDI specialists align your documentation to the specific clinical criteria your payer requires before submission. You receive InterQual-aligned documentation for UHC and commercial denials. LCD and NCD compliance review is performed on all Medicare clinical denials. When needed, peer-to-peer review is coordinated directly with payer medical directors. Medical necessity denial management demands specialized expertise to overturn.
LCD and NCD pre-submission compliance review runs on every Medicare claim. ADR response packages come prepared with complete documentation. The Medicare Advantage 60-day appeal window is tracked automatically. IRO escalation is pursued when plan-level appeals fail. Our Medicare denial management and Medicare Advantage denial management handle original Medicare and MA with separate workflows, because they require them.
State MCO policy compliance is monitored per plan. Retroactive authorization is pursued for every eligible denied claim where that window remains open. State-specific appeal workflows are built per MCO. Our Medicaid denial management approach is built around your specific MCOs, because denial rates vary significantly by state and a generic process won't work.
Denied claims integrate into full accounts receivable denial management follow-up so nothing sits unworked in aging buckets. High-dollar denials near timely filing deadlines are prioritized automatically. Aged denial recovery is pursued for previously written-off claims when the window allows. Our ar denial management in medical billing drives your write-off rate below 1% so revenue doesn't sit in the queue.
Payer-specific denial scorecards are produced monthly for your practice. Predictive claim scoring flags at-risk claims before submission. Workflow updates and staff training are delivered when recurring patterns are identified. Our claim denial management services aim to eliminate recurring denials permanently while recovering everything already denied. Prevention ROI is tracked alongside recovery ROI every single cycle.
One O Seven provides claim denial management services across all 50 states, including the six WISeR model states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, where new prior authorization workflows are now required.
Every specialty has unique payer denial patterns. Our claim denial management services team maps the most common denial triggers for your specialty by payer before we start.
We’ve built denial workflows for more than 75 specialties. If your specialty isn’t in the grid above, it’s almost certainly one we’ve already worked, won, and documented.
Automated payer policy bulletin alerts fire the moment coverage requirements change inside any payer’s system, not three claims later when the denials stack up.
Here’s the thing about payer policy. Payers update denial criteria regularly. Most practices don’t find out until a claim comes back denied. The clean claim from last month becomes a denial this month and nobody flagged the change. Our denial management system catches the policy update before it costs you the claim.
Here’s the thing about payer policy. Payers update denial criteria regularly. Most practices don’t find out until a claim comes back denied. The clean claim from last month becomes a denial this month and nobody flagged the change. Our denial management system catches the policy update before it costs you the claim.
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