OB/GYN Claim Denial Management

Denials are a symptom — we treat the cause

Most practices handle denials one at a time: open the remit, fix what's obvious, resubmit, move on. That gets some claims paid, but it doesn't change the fact that the same denial will arrive again next week. In OB/GYN, where a single global maternity or surgical claim can represent thousands of dollars, repeat denials quietly become one of the largest drains on revenue.

Our denial management service does two jobs at once:

1. Recover the money. Work every denied claim — correct it, request reconsideration, or file a formal appeal with supporting documentation.
2. Stop the next one. Categorize every denial by root cause and fix the upstream process that created it: registration, eligibility, authorization, charge capture, coding or documentation.

With more than eight years of OB/GYN billing behind us, we've learned that denial patterns in women's health are remarkably consistent. Once you know where to look, most are preventable.

The denial codes we see most in OB/GYN

Claim Adjustment Reason Codes (CARCs) tell you what the payer did. Remittance Advice Remark Codes (RARCs) often tell you why. These are the CARCs that show up most often on OB/GYN remits:

For a closer look at the most common one, read our guide to the CO-97 denial code.

How we work a denial

1. Triage within days, not weeks

Every remittance is posted and every denial is logged, categorized and assigned the day it arrives. Appeal deadlines start running the moment the payer decides — waiting a month to look at a denial is one of the most expensive habits in medical billing.

2. Decide: correct, reconsider or appeal

• Corrected claim when the original claim had an error we can fix — a missing modifier, wrong diagnosis pointer, incorrect place of service.
• Reconsideration or reopening when the payer made a processing error or needs a simple clarification.
• Formal appeal when the payer's decision requires clinical or policy argument — medical necessity, bundling disputes, authorization exceptions.
• Patient responsibility when the denial is legitimate and the balance properly belongs to the patient, communicated clearly.
• Write-off only when nothing else applies — and every write-off is categorized so we know why.

3. Build appeals that win on the merits

An effective appeal is specific. It names the service, cites the payer's own policy or the CPT/NCCI guidance, attaches the relevant documentation (operative note, prenatal records, authorization number), and explains in plain language why the claim should be paid. Form letters get form-letter responses.

4. Track it to resolution

Every open appeal has a follow-up date. We escalate through the payer's appeal levels when a first-level appeal fails and the claim is worth pursuing.

Prevention: fixing denials upstream

The most valuable part of denial management is the report that tells you why claims are being denied. Each month we break denials down by category and by payer, then fix the source:

• Front-desk and eligibility denials → better insurance capture and re-verification at every trimester. See eligibility verification.
• Authorization denials → an authorization check matched to the scheduled CPT code before surgery or imaging.
• Coding and modifier denials → coding rules and payer-specific edits applied before submission, plus provider documentation feedback. See GYN surgery coding.
• Global package denials → a pregnancy registry that tracks visits, payers and delivery type. See global maternity billing.
• Credentialing denials → enrollment monitored so new providers aren't billing before they're effective with a payer. See credentialing.

Payers we work with

We work denials with the commercial, government and managed care payers OB/GYN practices bill most often, including Medicare, state Medicaid programs and Medicaid managed care plans, UnitedHealthcare, Aetna, Cigna, Blue Cross Blue Shield plans, Anthem, Humana and TRICARE. Each has its own appeal process, portal and deadlines, and we keep a payer-specific playbook for each.

Appeal timelines you should know

• Medicare (traditional): first-level redetermination within 120 days of the initial determination; second-level reconsideration by a Qualified Independent Contractor within 180 days of the redetermination decision; further levels after that.
• Medicare Advantage, Medicaid managed care and commercial plans: set by contract and plan policy, commonly 60–180 days for provider appeals.
• Timely filing for original claims: 12 months from date of service for Medicare; often 90–180 days for commercial plans. Global OB claims that wait for a postpartum visit before billing are at real risk here.

What you'll see from us

• A denial log you can review at any time
• A monthly summary of denials by reason, payer and provider
• A list of the top preventable denial causes and what we changed to fix them
• Aged A/R and open appeals with next actions

We report what's actually happening in your A/R. We don't promise a specific denial rate before we've seen your data, because every practice's payer mix and starting point are different.

Denial prevention checklist for your front desk and providers

• Verify insurance and coordination of benefits at every visit, and re-verify during pregnancy
• Confirm authorizations match the scheduled CPT codes and facility
• Hold surgical claims until the pathology report is final when weight or diagnosis affects coding
• Document the reason for any separately billed service on the same day as a global or preventive service
• Bill corrected claims with the proper frequency code instead of sending duplicates
• Submit global OB claims promptly after delivery to stay well inside timely filing limits

Start with a free denial review

Message us on WhatsApp and we'll look at a sample of your recent remittances and denials. You'll get a clear picture of your most common denial reasons and what it would take to fix them — no form, no contract and no cost. Want a rough estimate first? Try the revenue leakage calculator.