RecoveAR · Denial Yield Model

Work the denials worth the money, not the oldest ones in the queue.

Here is the short answer. A denial is worth working when the dollars you can realistically recover beat the effort to appeal it, and you can still hit the filing deadline. RecoveAR scores every line on those three things the moment the 835 posts, then routes your team to the highest yield work first. Aging becomes one input, not the whole strategy.

Expected $ Recovered ÷ Effort to Win × Deadline Urgency = Yield Score

The inputs

Four things decide whether a denial earns your team's next hour

Oldest-first treats a $38 patient-responsibility adjustment the same as a $4,100 clinically appealable downcode. Yield-first does not. Every denial that lands on the 835 gets read against these four factors before anyone touches it.

FACTOR 01

Billed dollars at stake

The allowed or charged amount tied to the denied line. Nothing else matters if there is no money behind it.

drives ↑ yield

FACTOR 02

Recovery probability

Read straight from the CARC and RARC on the 835. A missing-auth denial overturns very differently than a true non-covered service.

drives ↑ yield

FACTOR 03

Effort to win

Touches, records pulls, and payer portal time. A one-click resubmit and a full medical-necessity packet are not the same job.

drives ↓ yield

FACTOR 04

Days to deadline

The payer appeal clock. A high-dollar denial with 6 days left jumps the line over a bigger one with 90 days of runway.

forces ↑ urgency

Try the model

Denial-yield calculator

Drag the sliders the way you would size up a denial on your worklist. The panel scores it live and tells you where it belongs. Pick a real CARC to auto-set a starting recovery likelihood, then adjust to your own experience with the payer. These are your numbers, not ours, so nothing here is a claimed benchmark.

RecoveAR · Yield Scoring Engine

Billed dollars on the denied line $1,800

Recovery probability 55%

Effort to win (analyst touches) 3

Days left on appeal clock 45

Yield Score

WORK NOW

Expected recovery$990

Value per touch$330

Illustrative model using your own inputs. Recovery probability and effort come from your payer mix and denial history, not a published figure. RecoveAR calibrates these against your posted 835s in production.

Under the hood

From 835 posting to a ranked worklist

RecoveAR does not ask analysts to guess. It reads the standardized remittance the payer already sent and turns codes into a priority order.

Ingest the 835

Every ANSI X12 835 remittance posts automatically, line by line.

X12 835

Parse CARC + RARC

Each adjustment carries a reason code and group code that name why it was denied.

CARC / RARC

Estimate recovery

Code plus payer plus service maps to a realistic overturn likelihood from your own history.

expected $

Weigh effort + clock

Workflow type sets effort, the filing rule sets days remaining.

urgency

Rank the worklist

Analysts open the highest-yield denial next. No hunting, no oldest-first drift.

yield rank

The shift

Oldest-first versus yield-first

What the queue does	Oldest-first worklist	RecoveAR yield-first
Order of work	By date the denial aged in	By expected recovered dollars per hour
Small nuisance denials	Get the same attention as big ones	Batched, auto-corrected, or written off on rule
Near-deadline high-dollar denials	Can time out while buried in the stack	Surfaced first while still appealable
Analyst decision	Judgment call, denial by denial	Open the top of the list, it is already ranked
What leadership sees	Count of denials worked	Recoverable dollars protected and at risk

Why the clock is a factor, not a footnote

Appeal deadlines are hard walls, and they vary by payer

A high-yield denial is worth nothing once the filing window closes. RecoveAR loads the deadline rule for each payer, so urgency is scored against the real clock rather than a guess. A few of the anchors it tracks:

Medicare redetermination 120 days

First-level Medicare fee-for-service appeal must be filed within 120 days of the remittance advice date, per the CMS Medicare Claims Processing Manual, Chapter 29.

Commercial and Medicaid managed care typically 90 to 180 days

Each payer sets its own internal appeal window in the provider manual and contract. RecoveAR stores the specific clock per payer rather than assuming one number.

State Medicaid fee-for-service per state manual

Timely filing and appeal windows are set in each state Medicaid provider manual and differ state to state. These drive the urgency multiplier line by line.

The language of the 835

Reading recovery likelihood from the codes payers already send

Denials are not a mystery. The 835 tells you why in a standardized code set. RecoveAR treats each Claim Adjustment Reason Code, its group code, and any Remittance Advice Remark Code as the first signal of whether an appeal is winnable.

CO-197CO

Precert or authorization absent. Often recoverable with a retro-auth path or documentation. High expected yield when the service was medically appropriate.

CO-16CO

Claim lacks information, usually paired with a RARC pointing at the exact field. Frequently a low-effort correction and resubmit.

CO-45CO

Charge exceeds the fee schedule or contracted rate. A contractual writeoff, not an appeal. Low yield to work, high value to route out of the queue.

CO-50CO

Not deemed medically necessary. Winnable but effort-heavy. Needs records and a clinical argument, so it scores on dollars against work.

PR-204PR

Service not covered under the plan, patient responsibility. Usually low recovery probability. Better as a patient statement than an appeal.

Group codesCO·PR·OA·PI

The X12 group code, Contractual, Patient Responsibility, Other Adjustment, or Payer Initiated, sets who owns the balance and whether an appeal even applies.

The standards this model is built on

ASC X12 835 (Health Care Claim Payment/Advice), the standardized electronic remittance transaction whose CARC and RARC fields RecoveAR parses to explain every denial.
Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC), the national code sets maintained through the X12 code maintenance committees and referenced by CMS for Medicare remittance.
X12 Claim Adjustment Group Codes: CO, PR, OA, PI, which classify each adjustment as Contractual Obligation, Patient Responsibility, Other Adjustment, or Payer Initiated Reduction.
CMS Medicare Claims Processing Manual, Chapter 29, the 120-day filing window for a first-level Medicare redetermination measured from the remittance advice date.
Payer provider manuals and state Medicaid provider manuals, the source of each payer-specific appeal and timely-filing deadline that drives the urgency factor.

Stop paying analysts to work the cheapest denials first

RecoveAR is ASP-RCM Solutions' AI denial management and recovery engine. It reads your posted 835s, scores every denial by expected recovery against effort and appeal deadline, and hands your team a worklist ranked by dollars, not by date. Same headcount, aimed at the money that is actually recoverable and still in the appeal window.

Score your denials with RecoveAR → See the yield model run against your own remittance data.