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RCM & insurance

Work a denial with the right owner and deadline

Separate correction, evidence, reconsideration and appeal while preserving patient-liability controls.

Current source · source reviewed · 8 min read

Before you begin

1. Open the Denial workbench

Identify the claim, reason category, responsible team, required evidence, recovered amount and current disposition. Check whether the item is truly a denial rather than a platform or business error.

Three synthetic denials populate the worklist; initially missing responsibility configuration must be resolved before an appropriate remedy is established.
Open the synthetic denial worklist · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. Three synthetic denials populate the worklist; initially missing responsibility configuration must be resolved before an appropriate remedy is established.

2. Read deadlines from receipt

Review deadline calculation using the received timestamp, applicable instrument and calendar/working-day basis. A response waiting unread has already started aging.

The current denial view explicitly refuses to establish a remedy where its responsibility map and deadline instruments are missing; no default remedy is assumed.
Recognize an unconfigured denial remedy · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. The current denial view explicitly refuses to establish a remedy where its responsibility map and deadline instruments are missing; no default remedy is assumed.

3. Choose the supported remedy

Select correction, information_response, reconsideration or appeal according to the recorded map and evidence. Each action requires its own payload; an empty justification is refused.

For the tested reconsideration, the Billing Officer supplied a synthetic claim-line reference, a justification and a supporting-reference placeholder. The placeholder is not proof of an uploaded document. The endpoint records the local claim-level remedy; no payer transmission was tested.

The Billing Officer supplied a real synthetic claim-line reference, training justification and a supporting-reference placeholder. No file upload or live payer exchange is represented.
Supply the reconsideration payload · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. The Billing Officer supplied a real synthetic claim-line reference, training justification and a supporting-reference placeholder. No file upload or live payer exchange is represented.

4. Record and follow the action

Retain original claim references and action history. Use a request key or supported idempotency header in integrations to avoid duplicate remedy recording.

The saved example shows Contested adjudications (1). Independent database readback confirms one recorded reconsideration and its fields. Clinical/coding corrections and financial concessions remain separate history tracks.

Remedy history shows one contested adjudication after the actual UI save. Independent database readback confirms the synthetic line, justification and evidence-reference placeholder; no payer request was sent.
Verify the persisted reconsideration history · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. Remedy history shows one contested adjudication after the actual UI save. Independent database readback confirms the synthetic line, justification and evidence-reference placeholder; no payer request was sent.

5. Review final responsibility separately

A denial reason explains why a payer rejected something; it does not establish who owes the residual. Do not transfer contractual or undetermined amounts to a patient.

Special handling

Clinical medical-necessity disputes require clinical evidence. Fraud handling has a separate path. Contractual adjustments are not recoverable denial work merely because a balance exists.

Scope limitation

The current remedy endpoint refuses line-level appeals where the required profile extension is unavailable. Use the supported claim-level route and original business identifier.

What the current screenshots demonstrate

These are current captures from an isolated Polyclinic training environment, using explicitly fictional insurance, response, authorization, remittance and policy fixtures. They demonstrate the displayed controls and scoped observations only. They do not establish live payer connectivity, a genuine insurer approval, regulatory qualification, production tax filing, a complete role/facility matrix or a cleared financial estimate.

Dispute routing is a separate local action

The current form selects a route from the dispute subject and records local routing history. The essential-benefit-package teaching example selects the Council route. This observed action did not send a complaint, email or API transaction to an external authority. Validate the applicable real instrument and organization process before external escalation.

A synthetic essential-benefit-package dispute selects the Council route. This action records local routing history; it does not send a complaint or message to an external authority.
Record a locally scoped dispute route · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. A synthetic essential-benefit-package dispute selects the Council route. This action records local routing history; it does not send a complaint or message to an external authority.

Troubleshooting

The desired remedy is rejected

Read the endpoint’s permitted remedies, missing payload fields and line-level scope limitation. Supply the correct evidence instead of substituting a generic resubmission.

Source evidence

References are pinned to the private MANSOQ source repository. Repository access is required to open these links.