Denial Management Phase
Most healthcare organizations silently write off millions in denied claims because they lack the infrastructure to fight back. Factum's Denial Management phase is purpose-built for law firms and reimbursement specialists who treat every denial as recoverable revenue.
Converting Denials Into Collected Revenue
Healthcare organizations that rely on generic RCM tools typically recover less than 60% of denied claims - not because the money isn't there, but because the workflow infrastructure to pursue it systematically doesn't exist. Factum closes that gap with a denial management engine that automatically classifies every denied claim by root cause, assigns the correct appeal strategy from day one, and routes high-value unresolvable denials directly into litigation preparation.
Automated Denial Categorization
Every denial is automatically classified by type - medical necessity, coding error, authorization, timely filing, or contractual - using CARC/RARC code analysis and AI-assisted pattern recognition.
Appeal Deadline Tracking
The platform calculates appeal deadlines based on payer contract terms and state law, assigning SLA timers to every denied claim. No deadline is missed - the system escalates before the window closes.
Root Cause Analytics
Beyond working individual denials, Factum aggregates denial data to surface systemic causes - specific payers, CPT codes, attending physicians, or front-end intake failures driving denial volume at scale.
Sovereign Denial Triage & Matrix Routing Workspace
Adjust denied claim volume and dominant payer to watch Factum's triage engine route each CARC/RARC code to the optimal resolution path - with live portfolio recovery scoring at the bottom. Every routing decision, deadline assignment, and escalation trigger runs automatically across the full portfolio in real time.
Total Denied Claims Ingested
1,200claims
Dominant Payer
Auto-Routed Claims
1,128
94% routing accuracy
SLA Breach Prevented
37
deadline violations stopped
Modifier inconsistency
$2,800
11d aging
Timely filing exceeded
$880
Coordination of benefits
$2,800
12d aging
Modifier inconsistency
$1,650
Modifier inconsistency
$2,800
8d aging
Modifier inconsistency
$880
Coordination of benefits
$420
13d aging
Modifier inconsistency
$680
11d aging
Coordination of benefits
$360
12d aging
Claim lacks information
$5,200
11d aging
Coordination of benefits
$4,100
13d aging
Bundled service
$880
13d aging
Sovereign Routing Matrix — 0 claims placed
Intake
Re-intake & eligibility re-verification
Dispute Resolution
Administrative appeals & demand letters
Litigation Prep
Merits scoring & suit authorization
Litigation Management
Active case coordination & deadlines
Billing
Corrected claim resubmission
Intake
Re-intake & eligibility re-verification
Dispute Resolution
Administrative appeals & demand letters
Litigation Prep
Merits scoring & suit authorization
Litigation Management
Active case coordination & deadlines
Billing
Corrected claim resubmission
Portfolio Recovery Intelligence — Live Calculation
Portfolio Recovery Probability Score
Based on 1,200 claims | Dominant payer: UnitedHealthcare | Factum AI triage score
Estimated Revenue Leakage Saved
Avg. Claim Value
$1,850
Auto-Route Rate
94.0%
Actionable Worklists | The "How" of Denial Management
Your denial team works from prioritized queues organized by appeal type, deadline urgency, and recovery value.
Clinical Appeal Queue – Challenging Medical Necessity Denials
Medical necessity denials require clinical evidence - and Factum AI extracts supporting documentation from the medical record automatically, building the appeal package before staff open the file.
Trigger Action:
The platform generates a draft appeal letter with clinical citations, attaches relevant medical records, and routes it to the appropriate clinical reviewer - cutting appeal preparation time from hours to minutes.
Administrative Appeal Queue – Resolving Coding and Authorization Denials
Coding errors, missing modifiers, and authorization-related denials are routed where staff correct and resubmit with the platform auto-populating the corrected claim fields.
Trigger Action:
For authorization-related denials, the platform checks whether retro-authorization is available and initiates the request in parallel with the appeal - maximizing recovery options.
Legal Escalation Queue – Routing High-Value Denials to Litigation
Denials that exhaust the administrative appeal process - and meet litigation value thresholds - are automatically escalated to Dispute Resolution with full denial history attached.
Trigger Action:
The platform calculates whether the claim's expected recovery justifies litigation cost and routes qualifying claims to legal counsel with the complete denial and appeal record pre-packaged.
Integrated Technology | How Denial Management Is Powered
Factum AI Clinical Extraction
For medical necessity denials, the AI engine scans the complete medical record to identify clinical indicators that support medical necessity - flagging the specific documentation that overturns the denial.
The system cross-references payer clinical policies against the patient record, identifying every applicable criterion the payer's own guidelines require to approve the service.
Denial Analytics Dashboard
Real-time denial analytics surface trends by payer, denial type, service line, and provider - enabling proactive intervention that prevents future denials rather than simply reacting to them.
Appeal outcome tracking measures success rates by denial category and appeal strategy, continuously refining the platform's recommended approach for each denial type.
The Transition | From Denial Management to Patient Billing
Once payer liability is fully adjudicated - through payment, settlement, or exhaustion of appeal rights - any remaining patient responsibility balance is transferred to the Patient Billing phase with full claim and payment history intact.
Automatic Trigger |
When payer adjudication is finalized, the platform calculates the patient's balance after all applicable adjustments and transfers the account to Patient Billing with a complete explanation of benefits summary pre-generated for the patient statement.