Recoverability triage methodology
Every claim in an aged queue is sorted by five factors in a fixed order. The rules are published here so a practice can check any decision in a Recovery opportunity report against them. There is no proprietary score; the method is the sequence.
The five factors, in order
| Factor | Question asked of every claim | Rule |
|---|---|---|
| 1. Deadline exposure | How many days remain on the timely-filing limit and on the appeal window? | Inside 30 days: worked first regardless of balance. Past both with no proof of timely filing: closed with reason. |
| 2. Recovery path | Which action does the denial reason (CARC/RARC) call for? | Not on file → refile with proof. Coding/modifier → corrected claim. Authorization or medical necessity → appeal. Underpayment → contract dispute. Eligibility/COB → rebill correct payer. |
| 3. Documentation on file | Do we already hold what the path needs (op note, auth record, EOB, clearinghouse report)? | Complete: work now. Missing: request from the practice with a due date; the claim is held, not closed. |
| 4. Payer behavior | How has this payer handled this reason before in this queue? | Reasons this payer overturns on first-level appeal are batched; reasons it never overturns go to escalation or contract dispute instead of another appeal. |
| 5. Balance | What is the expected allowed amount, not the billed charge? | Within the same deadline and path group, larger expected allowed amounts are worked first. |
Order matters: a claim is never advanced on balance until its deadline and path are known, and a documentation gap never causes a claim to be closed.
The four classifications
| Class | Meaning | Treatment |
|---|---|---|
| Actionable | Inside deadlines with a valid path and obtainable documentation. | Worked to remittance or final determination. |
| Pending | With the payer; no action available until it adjudicates or responds. | Followed on a schedule; escalated if the payer exceeds its own processing window. |
| Held | Needs documentation or a signature from the practice. | Requested with a due date; reported weekly until received. |
| Unrecoverable | Past every deadline with no proof of timely filing, true contractual adjustment, or confirmed non-covered. | Closed with a reason code and the deadline that closed it, for write-off. |
How the estimate is built
The Recovery opportunity report's estimated range is the sum of actionable claims' expected allowed amounts, weighted by recovery path. The weights are conservative and stated in the report's notes. Billed charges are never used as the basis; the allowed amount from the contract or the payer's historical allowed-to-billed ratio is. The low end assumes only first-level actions succeed; the high end assumes escalations and disputes also succeed.
What the method does not do
- It does not assign a numeric score to a claim or a practice.
- It does not predict payer decisions; it sequences work so deadlines are never the reason a claim is lost.
- It does not use patient identifiers. Triage runs on claim, payer, code, date, and amount fields.
As our recovery dataset grows, the payer-behavior factor will be informed by published MARR Intelligence benchmarks, with the method stated.
Sources
- X12, Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC)
- CMS, Medicare timely filing requirements
- CMS, Original Medicare appeals process and deadlines
Figures attributed to a source are that source's; commonly used benchmarks are labeled as such. Verify deadlines against your own payer contracts.