Denial rate
-0.6pp7.4%
Target: ≤ 6.5%88% to goal
Recovery rate (90d)
+4pp63%
Recovered $ ÷ Allowed amount
Target: ≥ 65%97% to goal
Avg days to appeal
-2.1d14.2d
Target: ≤ 12d85% to goal
AI denial brief · action-oriented
AIPrior-auth denials (CO-197) drove 35% of $ exposure this week, concentrated in Lakeshore BCBS. Recommended next action: open a project to fix the Cedar Hills auth workflow — it's the highest-leverage single fix (~$84k, cuts initial denial rate ~1.4pp). Draft-appeal automation is out of scope for now (needs record retrieval + doc evaluation).
Denials vs recoveries
Last 8 weeks · count
Reason mix
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Appeal workqueue
10 of 10 denials
| Claim | Patient · Payer | Reason | Amount | Age | Status | AI win | Action |
|---|---|---|---|---|---|---|---|
| CLM-77821 | Maria Hernandez BCBS · Lakeshore | CO-197 Prior auth not obtained | $12,450 | 12d | In appeal | 72% | |
| CLM-77810 | James O'Connor Aetna · Cedar Hills | CO-197 Prior auth not obtained | $8,420 | 18d | New | 81% | |
| CLM-77805 | Rebecca Stone Cigna · Riverside | CO-50 Not medically necessary | $7,820 | 9d | In appeal | 54% | |
| CLM-77798 | Carlos Rivera Medicare · Cedar Hills | CO-50 Not medically necessary | $9,120 | 6d | New | 61% | |
| CLM-77781 | Daniel Kim UHC · Northgate | CO-16 Missing remittance info | $6,480 | 4d | Resubmitted | 88% | |
| CLM-77762 | Linda Martinez Aetna · Lakeshore | CO-29 Timely filing | $14,200 | 38d | Lost | 12% | |
| CLM-77748 | Sofia Alvarez BCBS · Harbor | CO-45 Charge exceeds fee schedule | $2,140 | 22d | Won | 95% | |
| CLM-77731 | Thomas Wright BCBS · Northgate | CO-197 Prior auth not obtained | $4,280 | 11d | In appeal | 68% | |
| CLM-77712 | Aisha Patel UHC · Harbor | CO-16 Missing remittance info | $3,940 | 7d | Resubmitted | 84% | |
| CLM-77688 | Henry Tanaka Medicare · Harbor | CO-50 Not medically necessary | $5,210 | 14d | New | 49% |