TRIAGE
Denial Triage: First 48 Hours
Triage protocol for new denials. Prioritize by dollar amount, deadline urgency, and pattern frequency. Route to correct resolution path.
Start
Denial received. Triage in 60 seconds.
Sort the denial into a queue before any deeper review. Triage drives where it goes next.
Decision
If this a hard denial or a soft denial?
Hard denials require clinical review. Soft denials usually need a clean resubmission.
Action
CO-50 not medically necessary or CO-109
Skip to clinical review. Pull the medical record, identify the missing necessity element, and route to the clinical appeal queue.
Action
CO-16 missing info, CO-22 secondary, CO-197 auth
Resubmit with corrections. Add the missing modifier, the secondary payer info, or the auth number, then refile.
Decision
If the appeal deadline within 14 days?
Deadline distance determines queue priority, not denial severity.
Caution
Priority queue. Assign immediately.
A 14-day window leaves no room for re-routing. Assign to the on-call denial specialist before end of shift.
Resolved
Standard queue.
Review payer behavior pattern first. If this is the third denial from this payer this week, escalate the pattern before working the individual claim.
Save this and get alerts when it changes.
Free claim review. No credit card.