Denials
Why payers refused money, grouped the way a practice fixes it. Each reason is the largest refusal on the claim; the claim page lists every code.
Payments dated Aug 4, 2026 to Sep 29, 2026, as of Oct 7, 2026. Whole organization, every site.
Filtered to: site Main Campus, Eastgate Family Care or Riverside Orthopedics.
Denial rate
9.6%
48 of 501 claims, fully or partly
Refused
$17,431.72
Valued at the contract rate
Preventable before the visit
50.0%
$13,225.10: eligibility, authorization, payer order, enrollment
Codes in play
10
Distinct primary reasons
By kind of problem
- Prior authorization Front end11 · $6,325.00
- Eligibility Front end4 · $5,373.40
- Medical necessity 5 · $2,080.20
- Another payer is responsible Front end9 · $1,526.70
- Coding error 7 · $819.50
- Duplicate 3 · $546.96
- Missing or invalid information 4 · $428.18
- Not covered by the plan 2 · $186.44
- Bundled into another service 1 · $84.50
- Frequency or quantity limit 1 · $45.24
By payer
| Payer | Denied | Rate | Refused |
|---|---|---|---|
| Fernhollow Community Care | 9 of 93 | 9.7% | $1,058.46 |
| Granite Plains Mutual | 15 of 174 | 8.6% | $2,692.76 |
| Silver Mesa Senior Advantage | 10 of 113 | 8.8% | $4,977.00 |
| Tallow Creek Health Plan | 14 of 121 | 11.6% | $8,703.50 |
By provider
Which clinician's claims are refused, largest refusal first. A pattern here usually points at documentation, coding habits, or an enrollment gap.
| Provider | Denied | Rate | Refused |
|---|---|---|---|
| Dr. Tomas Varga | 2 of 23 | 8.7% | $2,605.00 |
| Dr. Martin Osei | 3 of 28 | 10.7% | $2,600.50 |
| Dr. Victor Adeyemi | 3 of 43 | 7.0% | $2,406.80 |
| Dr. Nina Castellano | 3 of 27 | 11.1% | $2,121.00 |
| Jordan Blake, PA-C | 3 of 46 | 6.5% | $1,874.60 |
| Dr. Owen Whitaker | 4 of 45 | 8.9% | $2,061.80 |
| Dr. Priya Raman | 4 of 46 | 8.7% | $747.04 |
| Maya Chen, NP | 4 of 44 | 9.1% | $646.84 |
| Dr. Grace Lindqvist | 4 of 46 | 8.7% | $539.70 |
| Dr. Samuel Ivers | 4 of 51 | 7.8% | $343.14 |
| Dr. Helen Park | 7 of 50 | 14.0% | $809.06 |
| Dr. Alana Reyes | 7 of 52 | 13.5% | $676.24 |
By location
Which site's claims are refused. A pattern here usually points at the front desk: eligibility checks, authorizations, or the wrong payer on file. Each location opens its site's claims.
| Location | Denied | Rate | Refused |
|---|---|---|---|
| Riverside Orthopedics | 25 of 239 | 10.5% | $14,096.14 |
| Eastgate Family Care | 9 of 109 | 8.3% | $1,732.90 |
| Main Campus | 14 of 153 | 9.2% | $1,602.68 |
Every reason, with the usual fix
| Payer reason code | What it means | Usual fix | Claims | At stake |
|---|---|---|---|---|
| 197 Prior authorization missing | Authorization or notification was required and not on file. | If authorization was obtained, appeal with the number. If not, write off; it cannot be billed to the patient. | 11 | $6,325.00 |
| 27 After coverage ended | The service date is after the patient coverage ended. | Verify eligibility for the service date and bill the plan that covered it. The patient can be billed only when the payer sends it as patient responsibility (group PR). | 4 | $5,373.40 |
| 50 Not medically necessary | The payer decided the service was not medically necessary. | Appeal with the visit note and any supporting records. | 5 | $2,080.20 |
| 22 Another payer may be primary | Coordination of benefits: the payer believes another plan should pay first. | Update coverage order with the patient and bill the primary plan. | 9 | $1,526.70 |
| 4 Modifier does not fit the code | The procedure code does not agree with the modifier billed, or a required modifier is missing. | Fix the modifier and send a corrected claim. | 7 | $819.50 |
| 18 Exact duplicate | The payer already received this exact claim or service. | Confirm the original claim was paid. If it was, no action is needed. | 3 | $546.96 |
| 16 Missing or invalid information | The claim is missing information or has a billing error. A remark code usually says which field. | Read the remark code, fix the field it names, and resubmit. | 4 | $428.18 |
| 96 Non-covered charge | The service is not covered. A remark code usually says why. | Bill the patient only if they signed a waiver or the plan allows it; otherwise write off. | 2 | $186.44 |
| 97 Bundled into another service | Payment for this service is included in another service on the same day. | If the service was separate and distinct, add the right modifier and send a corrected claim. | 1 | $84.50 |
| 151 More services than the payer allows | The payer says the information does not support this many services or this frequency. | Appeal with documentation supporting the number of services. | 1 | $45.24 |
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