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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
Prior Authorization Appeals Under the New 7-Day and 72-Hour Timeframes
Since January 1, 2026 Medicare Advantage and Medicaid managed care plans must decide standard prior authorization requests in seven days, expedited requests in 72 hours, and state a specific reason for every denial. Here is how to build an appeal around that reason, the deadlines on both sides, and a letter that works.
NCCI Edits Explained: Modifier 59, the X Modifiers and Bundling Denials (CO-97)
Bundling denials are the most misunderstood line on the remit. How the National Correct Coding Initiative edits work, what the modifier indicator means, when modifier 59 or the XE, XS, XP and XU modifiers are legitimate, the office procedure pairs that trip the edits most, and how to correct without unbundling.
Denial Trends After the January 2026 Payer Changes: What Q1 Remits Are Showing
Three months of 2026 remittances are enough to see which January changes turned into denials. We walk through the CARC codes that rose this quarter, the payer behaviors behind them, and the fixes that stop each category before April claims go out.
A Monthly Denial Review Template: The Eight Numbers and the One-Page Agenda
Most practices look at denials when cash is short and stop when it recovers. A monthly review with fixed numbers and a fixed agenda turns that into a habit. Here is the template we use: the eight measures, how to pull them, and the forty-minute meeting that goes with them.
Claim Rejection vs Denial: What the 277CA and the 835 Are Telling You
A rejected claim never entered the payer's system; a denied claim did and was refused. The two need different fixes, deadlines and reports, and practices that treat them the same lose claims to timely filing. Here is how to tell them apart, where each surfaces, and the workflow for both.
Prior Authorization Service Levels to Hold Payers to in 2026, by Payer Type
Between CMS-0057-F, the ERISA claims regulation, state laws and the insurers' voluntary pledge, most payers now owe you a decision within a defined window and a specific reason for a denial. Here is the service level table we use, and how to track whether each plan meets it.
How to Appeal a Timely Filing Denial: CO-29, Proof of Filing and the Letter
CO-29 denials are not always final. Clearinghouse acceptance reports, payer acknowledgments and eligibility history can prove the claim was filed on time or that the clock started later than the payer thinks. Here is what counts as proof, what does not, and the letter we send.
WISeR Starts January 1: Medicare Prior Authorization Comes to Six States
The WISeR model brings prior authorization to traditional Medicare for the first time at scale, in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, starting January 1, 2026. Skin substitutes, nerve stimulators, epidural steroid injections and knee arthroscopy are on the list. Here is how the workflow changes.
Denial Prevention for High-Dollar Procedures: A Pre-Claim Review That Pays
A denied $28,000 implant claim costs more than a hundred denied office visits. Here is how to define high-dollar claims, the eleven-point check before they leave the practice, a worked example, and why this matters more with WISeR arriving in January 2026.
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