Claim Denial Management & Resubmission

Automation monitors for claim denial emails from carriers or polls carrier portals for new denied claims. When a denial arrives, it extracts the claim number, patient name, and denial reason code.

The automation reads the denial email or portal data and extracts structured information: claim ID, patient name, denial code, and reason category (missing docs, eligibility, coding error, etc.).

Extracted denial details are automatically written denial log with timestamp, status, and category. This creates a single source of truth for all open denials.

Based on denial reason, the automation sends a notification to the billing coordinator with a summary and next steps. For missing docs, it includes a template request; for coding errors, it flags the claim for review.

Automation retrieves the original claim details and patient eligibility info or the practice management system, and attaches it message so the coordinator has context without manual lookup.

For denials caused by missing documentation or minor coding errors, the automation resubmits the claim to the carrier via EDI or API, or prepares a corrected claim file ready for manual upload if the carrier system requires it.

Once resubmitted, the automation updates the log with resubmission date and status. It also sends a confirmation so the team knows the claim is back in the queue.

Automation polls the carrier portal daily to check if resubmitted claims were accepted or denied again. If accepted, it marks the denial as resolved in the tracker. If denied again, it re-routes to the coordinator with the new reason.