- comes inDenied claimClaim 30417PayerRegional PPOServiceInitial evaluationAmountStatusDeniedReason197, no authorization on fileagents read it againstThe payer's own ruleProvider manual
Initial evaluations need a referral on file. No prior authorization is required.
Section4.2, EvaluationsReferral on fileYes, datedagents draftAppeal, ready to sendClaim 30417ToRegional PPO, appealsCitesProvider manual, sec. 4.2AttachedReferral, eval noteStatusAwaiting signatureA person signs and sendsA denied claim, read against the rule, appealed.
Claim denials fell from 12% to 1.5% at a healthcare group.
Brandon founded the group, built its claims and denial agents, and sold it.
The agents still run daily for the buyer, across seven locations.
Read the case: Claim denials fell from 12% to 1.5% at a healthcare group.
