Claim Denial

An insurer's refusal to pay a submitted claim, often over missing documentation, coding errors, or lack of prior authorization.

A claim denial is a payer's decision not to pay a billed service. Many denials are administrative — a missing modifier, an expired authorization, or incomplete documentation of medical necessity — rather than disputes about the care itself.

Act fast. Most carriers will reverse a documentation-based denial if you respond with a corrected note inside their initial appeal window. After that, recovery rates fall sharply, so a tight appeal workflow protects significant revenue.

Related terms

Prior Authorization

An insurer's advance approval required before certain treatments or imaging will be covered — a common source of denials when skipped.

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Explanation of Benefits

EOB

A statement from an insurer showing what was billed, what was allowed, what was paid, and what the patient may owe.

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Revenue Cycle Management

RCM

The end-to-end process of capturing, billing, and collecting revenue for care — from patient intake through final payment.

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