Authorised, but more units or visits were billed than approved.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Usually recoverable. Appeal it. The money is usually there.
In the order we see it.
More units or visits were billed than the authorisation approved.
A second episode of care was billed under the first episode's authorisation.
Appeal for the extra units with the treatment notes, or request a retro-extension.
The documentation, not the argument.
Treatment notes showing medical necessity for the units beyond the approval.
A re-authorisation request covering the additional units.
The common mistake. Do not write off the whole claim. Usually only the excess above the approved units was denied, and the rest paid.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound