> ## Documentation Index > Fetch the complete documentation index at: https://dso.getlemma.com/llms.txt > Use this file to discover all available pages before exploring further. # Work the denial queue > Route downgrades and limitations out first, triage true dental denials by CARC family, the fix-versus-appeal decision tree, aging rules, and the prevention feedback loop. The **denial queue** holds adjudicated claims that were not paid in full after benefit-design reductions have been routed elsewhere. Use it both to recover payment and to identify upstream changes that prevent the same denial from recurring. ## Prerequisites * Posting configured so denials route to the queue rather than to write-off * Posting configured so **downgrades and limitations route to the patient ledger** rather than the denial queue; see [Post payments from 835s](/guides/billing/post-payments-from-835s) * A fixed root-cause taxonomy * Appeal deadlines recorded per payer * Fee schedules loaded, so underpayments surface ## What doesn't belong in the queue Dental remittances are full of reductions that look like denials and aren't: * **Downgrades (alternate benefit or LEAT).** The plan may pay a posterior composite at the amalgam allowance. Where the contract permits, route the difference to the patient ledger instead of appealing or automatically writing it off. * **Frequency limits and exhausted maximums.** Examples include a third cleaning in one year, a crown within the replacement window, or an annual maximum reached in October. Apply the plan terms and financial-consent policy to determine the patient balance. If these are landing in your queue, the fix is upstream in posting configuration, not in how you work the queue. See [Denials vs downgrades](/concepts/payments/denials-vs-downgrades). ## The daily loop Group them, because the fix is per-family rather than per-claim: | Family | CARCs | Typical fix | | ---------------------------------- | -------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Missing attachment / documentation | 16, 252 | Send the radiograph, perio chart, or narrative the payer wants; resubmit or respond to the RFI | | Necessity | 50 | Review the clinical documentation; appeal with x-rays and a narrative if the work was justified | | Preauthorization | 197, 198 | Common on Medicaid and DHMO claims. If a required preauthorization was missing or expired, check for a retroactive-authorization path. Otherwise, the amount may be unrecoverable. | | Eligibility | 26, 27, 31, 32 | Verify coverage, correct the insurance record, rebill | | Bundling | 97 | Payer bundled the service into another (a buildup into the crown, radiographs into the exam); rebut with clinical justification or accept per the contract | | Timely filing | 29 | Appeal with proof of submission | | Coordination of benefits | 22, 23 | Determine the order, apply the birthday rule where appropriate for dependent children, bill the primary plan, and ask the patient to update COB if needed | | Credentialing / enrollment | 8, 185, 206 | Resolve with payer enrollment, then rebill | | Duplicate | 18 | Check whether staff resubmitted an original instead of correcting the claim, or whether a tooth or surface mismatch conflicts with payer history | | Non-covered | 96, 204 | Review the benefit design, including missing tooth clauses, waiting periods, and excluded services. The result may be patient responsibility or a write-off and is rarely appealable. | Full detail per code: [Denial code playbook](/reference/edi/denial-code-playbook). Ten $40 bitewing denials matter less than one $900 crown denial. Sort the queue by amount, descending, within age bands. ```mermaid theme={null} graph TB A[Denial] --> B{Was the claim data wrong?} B -->|Yes| C[Corrected claim
frequency code 7
reference original] B -->|No| D{Was the payer's
determination wrong?} D -->|Yes| E[Formal appeal with
clinical documentation] D -->|No| F{Patient responsibility
under the contract?} F -->|Yes| G[Move to patient ledger] F -->|No| H[Write off, with a
root-cause tag] ``` | | Corrected claim | Appeal | | -------- | ------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------- | | Use when | The claim had wrong or missing data, such as a wrong tooth number, missing attachment, or stale subscriber ID | The submitted claim was correct, but the payer's adjudication was not | | Speed | Days to weeks | Weeks to months | | Deadline | Corrected-claim window, often shorter | Appeal window per contract | A missing-attachment issue sits between the two because the claim data may be correct but incomplete. Respond through the payer's designated channel, often by sending the attachment through the clearinghouse service and placing its reference number on the resubmission. A formal appeal may not be necessary. Eligibility · Preauthorization · Attachment missing · Coding / tooth data · Documentation · Credentialing · Timely filing · COB · Demographic error · Payer error · Benefit design. **Free-text root causes are useless in aggregate**, which defeats the entire point of tagging. Use a closed list. **No denial sits untouched longer than 14 days.** Appeal windows are short, and a denial nobody has looked at is a denial you are about to lose. Make the age of the oldest untouched denial a tracked metric. Rank root causes by dollars. Change **one upstream control per week**. Verify next week that the cause dropped. Change the workflow when a denial recurs. If crowns keep denying for missing x-rays, use a scrubber or PMS edit to attach the image to the initial claim. If Medicaid claims keep denying for missing preauthorization, add the check to scheduling. See [Build the billing rhythm](/start/first-90-days/build-the-billing-rhythm). ## What not to write off **Do not bill a CO denial to the patient.** Group code CO identifies a contractual obligation. CO-197 for missing preauthorization is a common dental example. Billing the patient may breach the participation agreement and, on Medicaid claims, generally violates program rules. And **do not write off a denial before assessing appeal rights.** A write-off is a decision to abandon the money, and it should be a deliberate one with a root-cause tag, not a default. ## Underpayments belong here too An underpayment can be easy to miss because the payer sends money and closes the claim. Load contracted fee schedules so posting can flag allowed amounts below the expected rate. Underpayments often follow a pattern. An incorrectly loaded fee schedule may affect every instance of the same code, while a leased-network arrangement may reprice a broader group of claims. Aggregate similar claims before disputing them. A single \$\$12 difference may not justify a call, but two hundred matching differences support a formal configuration review and request for retroactive correction. See [Underpayments and contracts](/concepts/payments/underpayments-and-contracts) and [Network leasing](/concepts/payments/network-leasing). ## Metrics for the queue | Metric | Target | | ------------------------------------ | --------------------------------------- | | Denial rate | Under 5–10% of adjudicated lines | | Oldest untouched denial | Under 14 days | | Denials resolved within 30 days | 80%+ | | Appeal overturn rate | Track your own, by payer and reason | | Denial write-off as % of net revenue | Under 1–2% | | Top root cause by dollars | Should change over time as you fix them | That last one is the real signal. If the same root cause tops the list for three months, your prevention loop isn't working. ## Verify it worked * [ ] Downgrades and limitations routed to the patient ledger, never to the queue * [ ] Denials route to the queue, not to auto-write-off * [ ] Triaged by CARC family, prioritized by dollars * [ ] Fixed root-cause taxonomy in use * [ ] Nothing untouched over 14 days * [ ] Corrected claims use frequency codes and reference the original * [ ] CO-denials never billed to patients * [ ] Underpayments flagged and aggregated * [ ] One upstream control changed per week, and verified ## Common failure modes | Failure | Consequence | | ----------------------------------------------- | ------------------------------------------- | | Downgrades worked as denials | Appeal capacity wasted on benefit design | | Working by date received rather than by dollars | Small denials consume the time | | Free-text root causes | No aggregate signal | | Denials aging past appeal windows | Unrecoverable | | Resubmitting instead of correcting | CARC 18 duplicates | | Writing off before assessing appeal rights | Abandoned recoverable revenue | | Billing patients for CO-denials | Contract breach; Medicaid program violation | | Working the queue but never changing upstream | The same denials, forever |