CleanClaimRx · Free Tool
Denial Root Cause Diagnostic
Not all denials are equal. A 5% denial rate on high-dollar surgical claims outranks a 20% denial rate on $25 vaccine codes every time. Enter your denied dollars by category — get a dollar-weighted action plan that tells you exactly what to fix first, what to fix next, and why.
How to use this tool: Pull your denial summary report from your clearinghouse or practice management system. For each denial category, enter the total denied dollars for the month and the number of denied claims (optional but improves the analysis). Select whether the denials are concentrated at one payer or spread across multiple — this changes the root cause and the fix.
Where to find this data: In most clearinghouse portals (Availity, Change Healthcare, Office Ally, etc.), look for a "Denial Summary by Reason Code" or "Denial Analysis" report. Group the reason codes into the categories below. Your practice management system may also have a denial dashboard — look for a report that shows denied dollar amounts by denial reason category for the current month.
All claims sent to payers this month
Total claims returned as denied
Required — sum of all denied charges this month. Find this in your clearinghouse denial summary report.
Running Total
Dollars categorized: $0
Denied Dollars by Category — Enter what you know, skip what you don't
Eligibility / Coverage
Patient not covered, inactive insurance, wrong plan billed, coverage terminated
Prior Authorization
Missing authorization, expired auth, wrong service authorized, auth not obtained
Coding Errors
Wrong CPT code, missing or incorrect modifier, unbundling, diagnosis code mismatch
Medical Necessity / Documentation
Service not medically necessary, insufficient documentation, doesn't meet coverage criteria
Timely Filing
Claim submitted after payer's filing deadline — these denials are generally unrecoverable
Duplicate / Coordination of Benefits
Duplicate claim submission, COB sequencing errors, primary/secondary payer issues
Other / Uncategorized
Use this category only for denied dollars you cannot yet assign to a specific root cause. It is included in your totals, but it will not generate a root-cause recommendation. Review your denial report and classify these claims before assigning corrective work.
Your Denial Priority Action Plan
Ranked by dollars at risk. Highest-impact problems first.
Save Your Action Plan
Download a printable copy or set a reminder to re-run this diagnostic in 30 days.
📅 Measure Whether the Fix Is Working
Run this diagnostic again after 30 days using your next monthly denial report. Compare denied dollars by category — not only total denials — to see whether the highest-impact problem is improving.