- 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 sendsDenied, read against the rule, appealed.
Claim denials fell from 12% to 1.5%, about $400K a year recovered.
At a healthcare group Brandon founded and sold, agents verify coverage before the visit and read every denial.
The agents still run daily, maintained for the buyer.


