# Claim denial management and appeals > Claim denial management and appeals: Denial reason, appealable, evidence Checked: checked by the outcome. Produces appeals, corrected claims. Source: https://www.sumarity.ai/library/claim-denial-management-and-appeals/ Healthcare # Claim denial management and appeals Reads denials, the patient record, payer policies. Produces appeals, corrected claims. Code works out every figure, the Judgement Engine answers the narrow questions, and whatever stays uncertain goes to a person. Checked by the outcomeClaims, disputes and exceptions Start from this workflowMore for healthcare What it decides ## Narrow questions, each with a check behind it. Denial reason, appealable, evidence Checked by the outcome: appeal result. The truth arrives later: a payment, an appeal's result. Until the measured record earns more, people review a sample of what settles. | Reads | Denials, the patient record, payer policies | Produces | Appeals, corrected claims | Who signs | A person on your team, with every figure traced to its document and every call on record | Process | Claims, disputes and exceptions | Industry | Healthcare See it run ## Every line, decided where it's safest. An example run. Each stage lights up as a line is decided there; pick a stage to see its lines. ReadsDenials, the patient record, payer policiesCodeReads, matches, ties out and works out every figure.JudgementDenial reason, appealable, evidence. Settles when it clears the cutoff; people review a sample until the outcomes prove it.A personGets whatever stays uncertain, with the evidence. Their ruling tunes the next run.ProducesAppeals, corrected claims Claim denial management and appeals · example run Example run | Ref | Item | Value | Decided by | DN-401 | CO-16 missing informationModifier missing: correct and resubmit · 0.94 | 320.00 | Engine · settled | DN-402 | CO-29 timely filingSubmitted on time, proof attached | 180.00 | Code · appeal | DN-403 | CO-50 not medically necessaryNotes support it? Clinical review | 1,200.00 | To a person | DN-404 | CO-18 duplicateOriginal claim paid | 95.00 | Code · write-off | DN-405 | CO-97 bundledSeparately billable with modifier 59 · 0.88 | 140.00 | Engine · settled | Settled 4 To a person 1 Settled wrong 0 Illustrative lines. Amber rows are the Judgement Engine's calls; each settles only above its cutoff and when its check agrees. What it could save ## Your volumes in. Your hours out. In our tests, between 24% and 42% of items still went to a person after tuning. Set your own share; a pilot measures it on your data. Items per run Runs per month Minutes per item by hand Cost per hour Share of items that still need a person: 30% By hand today80 ha month With Sumarity24 ha month, for the items people decide Saved56 hCHF 53,760 a year Related ## Start from what's closest. ### Claims, disputes and exceptions in other work Finance ### Customer deductions and short-pay disputes Valid deduction (promotion, damage) or not Proven by codeBanking ### Payment exceptions and investigations Why a payment failed or is queried; the action Proven by codeBanking ### Card disputes and chargebacks Network reason code; evidence enough to fight Cross-checked ### More for healthcare ### Remittance posting and payer reconciliation (835s) Which claims a remittance pays; adjustments Proven by code ### Prior authorisation Criteria met from the record Cross-checked ### Medical coding audit Codes supported by the notes Cross-checked Questions ## What buyers ask What happens when Sumarity isn't sure? Nothing settles below the cutoff, or when the check disagrees. The item goes to a person in the inbox with what the engine saw, its best answer and the runner-up. The person's ruling is kept and tunes the next run. How are its judgements checked? The truth arrives later: a payment, an appeal's result. Until the measured record earns more, people review a sample of what settles. Can we change it to fit how we work? Yes. Start from this workflow and describe your differences in plain words. The design assistant revises it, the validator checks it, your expert reviews it on the canvas, and your admin publishes it. Does it read our files as they are? Yes: spreadsheets and CSV in any layout, PDFs, bank formats and e-mail attachments. Sumarity suggests how each column maps, proves the mapping on a sample and remembers it once a person confirms it. Where does our data go? Sumarity runs in Zurich. Your data, backups and logs are stored in Switzerland. How does it get better? Your team's rulings become an answer key. Better questions and cutoffs are proposed, tested on data they haven't seen, and published only when your admin approves. It improves itself, with permission. ## Start from this workflow. Run it on your data. A pilot runs alongside your own process for a few weeks, at our cost, and ends in a line-by-line comparison. Talk to usBack to the library