Denial resolution

Resolve claim denials using CARC/RARC codes and AI-generated appeal strategies

The denial resolution agent analyzes claim denials and generates payer-specific appeal strategies with deadlines and recommended actions.

Submit a denial

curl -X POST https://api-dev.rcintell.com/v1/agents/denial-resolution \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Claim denied for prior authorization not obtained",
    "carc": "197",
    "rarc": "N479",
    "ccn": "170001"
  }'

Request body

Field	Type	Required	Description
query	string	Yes	Description of the denial or question
carc	string	No	Claim Adjustment Reason Code
rarc	string	No	Remittance Advice Remark Code
denial_code	string	No	Denial reason code
claim_id	string	No	Original claim identifier
ccn	string	No	Facility CCN for payer context

Poll for results

When complete, the result includes:

{
  "job_id": "550e8400-...",
  "status": "completed",
  "result": {
    "denial_analysis": {
      "carc": "197",
      "carc_description": "Precertification/authorization/notification absent",
      "rarc": "N479",
      "rarc_description": "Missing prior authorization",
      "category": "Prior Authorization"
    },
    "appeal_strategy": {
      "recommended_action": "Submit retro-authorization request, then appeal",
      "steps": [
        "Contact the payer to request a retroactive authorization",
        "Gather clinical documentation supporting medical necessity",
        "Submit a formal appeal with the authorization number",
        "Include a letter of medical necessity from the treating provider"
      ],
      "deadline": "120 days from denial date (Medicare)",
      "appeal_level": "Redetermination",
      "success_likelihood": "moderate"
    },
    "payer_context": {
      "payer": "Medicare",
      "timely_filing": "12 months",
      "appeal_levels": ["Redetermination", "QIC", "ALJ", "Medicare Appeals Council", "Federal District Court"]
    }
  },
  "audit_tier": "green",
  "composite_score": 0.91
}

Common denial scenarios

CARC	Description	Common Resolution
4	Procedure code inconsistent with modifier	Correct modifier and resubmit
16	Missing information	Submit with required data
18	Duplicate claim	Verify original claim status
29	Filing limit expired	Check payer-specific deadlines
96	Non-covered charge	Appeal with medical necessity
197	Prior auth absent	Obtain retro-auth or appeal