ClearPath / Claims Lifecycle Map
confidential document
Claims Lifecycle Map
confidential
v2.1 / 2026-03
01 Full Lifecycle Flow — Claims Submission Through Resolution
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PATIENT journey PROVIDER operations PAYER processing DENIAL management Patient Encounter ambulatory / ED / IP / OP Registration check-in / demographics Receives Care clinical services Discharge checkout / instructions Receives EOB explanation of benefits Patient Responsibility deductible / copay / coins Eligibility Verification 270/271 transaction Prior Authorization if required by payer Clinical Documentation EHR / medical records CDI Review documentation improvement Medical Coding ICD-10 / CPT / DRG Charge Capture fee schedule / CDM Claim Scrubbing rules engine / edits Claim Submission 837 -> clearinghouse Payment Posting 835 / ERA PAID or DENIED? PAID closed 837 transmission 835 remittance DENIED Claim Receipt 277 acknowledgment Eligibility Check coverage verification Benefit Check plan limitations Auth Verification prior auth present? Medical Policy clinical criteria Code Edit Check CCI / NCCI edits Contract Check fee schedule Duplicate Check prior submissions ADJUDICATE decision Denial Identification ERA / 835 parsing Categorization technical / clinical / contract TYPE? TECH RESUBMIT Level 1 Appeal written / internal Level 2: Peer-to-Peer physician call Level 3: External IRO review Level 4: Regulatory legal escalation RESULT RECOVERED WRITE-OFF corrected resubmission C B A D E F G PATTERN DETECTION (cross-cutting) LEGEND: happy path (paid) denial path ClaimFlow intervention (click to expand) cross-lane reference
02 Setting-Specific Scenarios
ambulatory
The Prior Auth Denial
Dermatologist performs biopsy on suspicious lesion. Payer denies for missing prior authorization.
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what happened

Patient presents to dermatologist with irregular mole. Punch biopsy performed same day based on clinical judgment. Claim submitted with CPT 11102. Payer returns denial -- the plan requires prior auth for all outpatient surgical procedures, including skin biopsies.

denial code

CO-197: Precertification/authorization/notification absent

appeal path

Intervention B would have flagged this payer's auth requirement at scheduling. Intervention A catches it at claim scrubbing. On appeal, Intervention E assembles clinical urgency documentation citing medical necessity for same-day biopsy.

outcomes

Level 1 appeal overturn rate: 62%. Retro-auth success with supporting documentation: 78%.

$340 average recovered per claim
inpatient
The Observation Denial
CHF patient admitted for 3 days. Payer retroactively downgrades to observation status.
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what happened

Patient admitted through ED with acute CHF exacerbation. Treated for 3 days with IV diuretics, cardiac monitoring, and specialist consults. Payer reviews post-discharge and determines the case did not meet inpatient criteria under InterQual or Milliman guidelines. DRG payment downgraded to outpatient observation rate.

denial code

CO-50: Non-covered service (medical necessity not established for inpatient level)

appeal path

Intervention E pulls the full clinical timeline -- BNP levels, chest X-ray findings, O2 requirements, medication titration -- and maps each to InterQual criteria. Intervention F prepares the attending with a 1-page brief showing exactly which severity-of-illness criteria were met.

outcomes

Peer-to-peer overturn rate with prepared physician: 68%. Dollar impact is significant given DRG vs. observation rate differential.

$8,200 - $14,500 average recovered per case
emergency department
The Not-an-Emergency Denial
Patient presents with chest pain, workup negative for ACS. Payer denies ED visit as non-emergent.
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what happened

45-year-old male presents to ED with acute onset chest pain radiating to left arm. Full cardiac workup performed: troponin, EKG, chest CT. Diagnosis: GERD. Payer retroactively denies the ED visit, classifying the final diagnosis as non-emergent. This ignores the "prudent layperson" standard.

denial code

CO-26: Expenses incurred prior to coverage / non-emergency use of ED

appeal path

Intervention E assembles the appeal citing: presenting symptoms (not final diagnosis), prudent layperson standard, vital signs at triage, and the clinical decision-making that justified the workup. Intervention G flags if this payer has a pattern of retroactive ED denials -- potential for regulatory complaint.

outcomes

Level 1 overturn: 55%. State regulatory complaint (if pattern detected): often triggers blanket policy reversal.

$1,800 - $4,200 average recovered per visit
trauma
The Activation Fee Denial
Level II trauma activation for MVC patient. Payer denies the $10K activation fee as not separately reimbursable.
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what happened

Multi-vehicle collision patient arrives by EMS with suspected internal injuries. Level II trauma activation initiated per protocol. Full trauma team assembled. Patient stabilized, CT scans performed, admitted for observation. Payer denies the trauma activation fee, stating it is bundled into the facility fee or not a covered benefit under the plan.

denial code

CO-97: Payment adjusted -- bundling rules

appeal path

Intervention A flags trauma activation billing rules by payer at scrubbing. Intervention E builds appeal with: trauma team documentation, activation criteria met (mechanism of injury, vitals), ACS verification standards, and contract language supporting separate reimbursement.

outcomes

Contract-based appeal overturn: 40%. Often requires escalation to contract negotiation team.

$8,000 - $12,000 average recovered per activation
outpatient
The Bundling Denial
Knee arthroscopy with meniscectomy and chondroplasty. Payer bundles chondroplasty into meniscectomy.
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what happened

Orthopedic surgeon performs knee arthroscopy (29881 - meniscectomy, medial) and chondroplasty (29877) in separate compartments. Payer applies CCI edits and denies 29877 as bundled into 29881, despite the procedures being performed in different anatomical compartments with appropriate modifier -59 (distinct procedural service).

denial code

CO-97: Benefit included in payment for another service (NCCI bundling)

appeal path

Intervention A catches modifier issues pre-submission. Intervention G detects if this is a payer-wide pattern of bundling compartment-specific arthroscopy procedures. Intervention E assembles appeal with operative report excerpts showing distinct anatomical compartments and clinical necessity for both procedures.

outcomes

Level 1 overturn with modifier documentation: 72%. Pattern detection enables proactive coding adjustments.

$1,400 - $2,800 average recovered per case
03 The Numbers — Industry Denial Landscape
10-15%
of all claims denied on first submission
trending upward year-over-year
65%
of denied claims never appealed by providers
revenue abandoned without review
$262B
left on the table annually across U.S. healthcare
$43
average cost to rework a single denied claim
staff time + opportunity cost
44%
Level 1 appeal overturn rate (when actually filed)
<0.2%
of consumer-facing denials ever appealed
patients almost never fight back
04 ClaimFlow Value Summary

Save Time

Pre-submission scrubbing eliminates rework before it starts. Auto-categorization replaces hours of manual ERA parsing. Appeal assembly pulls clinical evidence and generates letters with payer-specific citations.

45-90 min per appeal reduced to 5 min of physician review

Recover Revenue

The triage engine ensures 100% of denials are worked, prioritized by dollar amount, overturn probability, and filing deadline. Appeal success rates increase with AI-assembled clinical evidence and prepared peer-to-peer briefs.

Target: zero unworked denials. Zero missed filing deadlines.

Avoid Costs

Predictive intelligence catches 40-60% of would-be denials before submission. Auth intelligence eliminates CO-197 denials. Continuous eligibility monitoring catches coverage gaps before claims hit the payer.

Prevent the denial, skip the rework entirely. $43 saved per prevented denial.
See the triage engine in action →
ClearPath Health — Claims Intelligence Platform · 2026 industry landscape → confidential — do not distribute