Most denial management programs treat every denial the same. The result is appeals that miss payer-specific rules, deadlines that slip because each payer has different windows, and overturn rates stuck at the industry median of 45% to 55%. RCMGen's payer-specific denial management service is structured the opposite way. Each major payer has a dedicated workflow, dedicated specialist coverage, and a payer-specific appeal playbook informed by the actual policy language, denial reason code patterns, and historical appeal outcomes for that payer.
RCMGen operates dedicated denial workflows for the major U.S. payers and payer categories:
Medicare and Medicare Advantage
CMS denial reason code expertise, ABN compliance, LCD and NCD determinations, RAC and SMRC audit defense, redetermination, and ALJ-level appeals.
Medicare and Medicare Advantage
State-by-state Medicaid plan workflows, eligibility verification edge cases, presumptive eligibility appeals, and managed care organization-specific submission rules.
Commercial PPO and HMO denials
UnitedHealthcare, Anthem, Aetna, Cigna, Humana, BCBS, and regional commercial plan workflows with payer-specific medical policy and appeal expertise.
Workers' compensation and auto claims
State-specific WC fee schedule application, auto liability claim coordination, Medicare Secondary Payer compliance, and lien tracking through claim resolution.
Self-pay and patient responsibility
Charity care qualification, financial assistance program routing, payment plan structuring, propensity-to-pay scoring, and statutory deadline preservation.
Tricare and military health denials
Tricare Prime, Select, and For Life claim workflows, military treatment facility coordination, and CHAMPVA dual-eligibility resolution.
Behavioral health and parity denials
Mental Health Parity Act enforcement, prior authorization disputes, level-of-care medical necessity appeals, and substance use disorder claim recovery.
Workers' federal program denials
FECA federal worker comp, Black Lung Program, Veterans Affairs claims, and federal employee health benefit plan-specific appeal protocols.
High-dollar and complex claim denials
Stop-loss claim recovery, transplant and oncology high-dollar appeals, out-of-network negotiation, and bundled payment dispute resolution.
How RCMGen's payer-specific denial management works
Discovery (week 1 to 2): We review your last 90 to 180 days of denials by payer, by reason code, by service line. We identify which payers are costing you the most, which denial reasons are most recoverable, and which workflows are leaking the most revenue.
Onboarding (weeks 2 to 6): Access setup, payer-specific workflow configuration, escalation paths to your internal team, KPI baseline establishment.
Active operations (week 6 onward): Continuous 24/7 denial work begins. Daily denial intake, payer-specific routing, appeal drafting, internal QA, submission, and follow-up. Weekly performance reporting. Monthly executive review.
Continuous improvement: Quarterly payer-specific trend analysis, root-cause prevention recommendations, front-end intervention proposals where the upstream fix is cheaper than the downstream appeal.
Get a free denial recovery report
Submit a deidentified denial export and receive a written 12-page diagnostic inside 5 business days. The report identifies which payers are costing you the most, which denial reason codes are driving the largest losses, and which aged denials are still recoverable. No PHI upload. No BAA. No contract.
