How to use this framework
For each denial category below, select the rate that most closely matches your facility's experience. If you do not track denials by category, use your best estimate — the goal is to identify which categories warrant closer review, not to produce an audited figure. Expand each category to see the documentation and process improvements with the highest recovery potential.
High-Impact
Prior Authorization Denials
Missed, expired, or insufficient authorization documentation
Your denial rate in this category
Why this matters
Prior auth denials are the most recoverable denial type. Most are administrative failures, not clinical ones — meaning the care was appropriate, but the paperwork did not precede or accompany it correctly.
Documentation & process targets
- Audit the prior 90 days of auth denials to identify whether the failure point is at intake, at the authorization request, or at the renewal step
- Establish expiration alerts at 10 days and 3 days before any active authorization lapses
- Confirm that authorization numbers are documented in the medical record, the billing system, and the clinical notes — not just one of the three
- Review whether authorization scope covers the services actually being billed, including therapy disciplines and specialty items
High-Impact
Clinical Documentation Denials
Medical necessity, missing physician orders, care plan alignment
Your denial rate in this category
The core problem
Clinical documentation denials indicate a disconnect between what the care team records and what billing requires. This is often a communication and training issue between clinical staff and the billing department, not a care quality issue.
Documentation & process targets
- Conduct a physician order audit: confirm that every billed service has a corresponding signed, dated order in the medical record
- Review care plan documentation to ensure that goals, interventions, and resident responses are recorded with enough clinical specificity to support medical necessity determinations
- Implement a pre-billing clinical documentation review for high-risk claims — specifically therapy services, wound care, and specialized nutrition support
- Establish a direct feedback loop between denied claims and the clinical staff who generated the underlying documentation, with specific examples
Moderate-Impact
Eligibility & Enrollment Denials
Lapsed coverage, enrollment gaps, spend-down verification
Your denial rate in this category
What drives this
Eligibility denials often trace to verification processes at admission that are either incomplete or not repeated at the first of each month. Medicaid enrollment can lapse between application and approval, and spend-down status changes are frequently missed.
Documentation & process targets
- Verify Medicaid eligibility on the first of every month for all current residents, not only at admission
- Identify any residents with pending applications and confirm a process is in place to capture retroactive coverage dates once approved
- Review spend-down cases for accurate tracking of the spend-down period and covered days
- Confirm that managed care Medicaid plan enrollment is separately verified from straight Medicaid — the billing rules and authorization requirements differ materially
Correctable
Billing & Coding Denials
Incorrect codes, duplicate claims, timely filing, modifier errors
Your denial rate in this category
Why this is correctable
Billing and coding denials are almost entirely process errors. They do not reflect a care delivery problem, a documentation problem, or a payer dispute — they reflect gaps in the revenue cycle workflow that have clear, defined solutions.
Documentation & process targets
- Run a timely filing audit: identify any claims approaching or past the filing deadline and accelerate their submission or escalate to appeals
- Review the modifier usage on therapy and ancillary claims for compliance with current payer requirements — modifier rules change, and outdated usage is a common coding denial driver
- Identify duplicate claim denials and trace them to their source: billing system configuration errors and manual re-submissions without tracking both generate duplicates
- Confirm that diagnosis codes on claims reflect the current ICD-10 version and align with the MDS assessment codes for the billing period
Denial Pattern Analysis
Select rates above
to see your analysis
Prior Authorization
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Clinical Documentation
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Eligibility & Enrollment
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Billing & Coding
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Highest-priority target
Ganavyx Advisory conducts structured denial pattern analyses that identify the root cause, quantify the revenue at risk, and deliver a prioritized improvement roadmap.
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