Solutions / Denial Analytics
Denial Analytics
Which denials are actually costing you, which are just contractual adjustments, and which will pay if you appeal.
Most denial reports are a pile of CARC codes sorted by count. That tells you nothing about what to work. The first job is classification — a CO-45 is a contractual adjustment, not a denial, and treating it as one wastes a biller's afternoon. GetMax separates true denials from adjustments and soft rejections, then ranks what is actually recoverable.
How the AI works
- 01
Classify
Every remittance line typed: contractual adjustment, true denial, soft rejection, patient responsibility, or needs review.
- 02
Rank by recoverable value
Sorted by what can still be collected inside the timely-filing window, not by raw count.
- 03
Find the pattern
The same payer, code and provider combination showing up weekly is a process problem upstream, and it gets named as one.
Humans in the loop. By architecture.
Classification is checked, not assumed. Lines the model is unsure about are marked for review rather than silently bucketed — a misclassified denial is worse than an unclassified one, because nobody goes back to look at it.
Questions, answered
Why does CO-45 keep showing up in our denial reports?+
Because most tools count it as a denial. CO-45 is the contractual adjustment between billed and allowed amounts under your payer agreement. It is normal, it is not appealable, and mixing it into denial counts inflates the number and hides the work that matters.
What counts as a soft rejection?+
A claim the payer did not adjudicate — rejected at the clearinghouse or front-end edit for missing or malformed information. It never entered adjudication, so it is corrected and resubmitted rather than appealed.
Can you work our existing denial backlog?+
Yes, and the first thing we do is classify it, because a large backlog is usually smaller than it looks once adjustments are separated out.
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