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 Eastgate Family Care, Riverbend or Riverside Orthopedics.
Denial rate
9.8%
34 of 348 claims, fully or partly
Refused
$15,829.04
Valued at the contract rate
Preventable before the visit
70.6%
$13,225.10: eligibility, authorization, payer order, enrollment
Codes in play
8
Distinct primary reasons
By kind of problem
- Prior authorization Front end11 · $6,325.00
- Eligibility Front end4 · $5,373.40
- Medical necessity 3 · $1,843.20
- Another payer is responsible Front end9 · $1,526.70
- Duplicate 3 · $546.96
- Bundled into another service 1 · $84.50
- Not covered by the plan 1 · $68.44
- Frequency or quantity limit 1 · $45.24
By payer
| Payer | Denied | Rate | Refused |
|---|---|---|---|
| Fernhollow Community Care | 7 of 66 | 10.6% | $939.12 |
| Granite Plains Mutual | 10 of 121 | 8.3% | $2,164.12 |
| Silver Mesa Senior Advantage | 6 of 78 | 7.7% | $4,528.00 |
| Tallow Creek Health Plan | 11 of 83 | 13.3% | $8,197.80 |
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. Helen Park | 7 of 50 | 14.0% | $809.06 |
| 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 43 | 9.3% | $646.84 |
| Dr. Alana Reyes | 4 of 7 | 57.1% | $406.90 |
| Dr. Victor Adeyemi | 3 of 43 | 7.0% | $2,406.80 |
| Jordan Blake, PA-C | 3 of 46 | 6.5% | $1,874.60 |
| Dr. Tomas Varga | 2 of 23 | 8.7% | $2,605.00 |
| Dr. Martin Osei | 2 of 23 | 8.7% | $2,386.00 |
| Dr. Nina Castellano | 1 of 22 | 4.5% | $1,885.00 |
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 |
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. | 3 | $1,843.20 |
| 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 |
| 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 |
| 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 |
| 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. | 1 | $68.44 |
| 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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