Handling denials

When a payer denies a billable, what changes in Rounds, and how to work denials systematically.

Updated 2026-04-24 · Edit this page on GitHub

title: "Handling denials" description: "When a payer denies a billable, what changes in Rounds, and how to work denials systematically." order: 3 category: "billables" updated_at: "2026-04-24"

Denied ≠ dead. Most first-pass denials are appealable. Rounds tracks the denial reason + timestamp so you can work a denial queue without re-keying data from the payer ERA.

Marking a billable denied

  1. On the Billables page, find the row
  2. Change status from submitted → denied
  3. Rounds prompts for a denial reason (free text or picked from the standard CARC/RARC codes if you paste them)
  4. Submit — Rounds writes a billable.status_changed audit row with the reason captured

If your clearinghouse is wired to Rounds via webhooks, denial status + reason come in automatically. See Webhooks for the payload shape.

Where denials show up

  • Billables page → filter by status=denied to see the queue
  • Insights → YTD Billables → monthly stacked bar shows denied vs paid vs submitted per month; denied-rate trending up = investigate
  • CSV export → include denied_at column for your denial-management workflow

The denial-reason field

We don't enforce a specific coding scheme. Most practices paste the CARC (Claim Adjustment Reason Code) from the payer's ERA, plus a short human-readable gloss. Example:

CO-22: Coordination of benefits — patient has primary coverage we didn't bill

The notes field on the billable is a good place for the full response details.

Appealing

When you win an appeal:

  1. Flip status from denied → submitted (Rounds asks for a short comment — "appealed + accepted on ERA 2026-04-30" is enough)
  2. Eventually flip to paid when the payment arrives
  3. The audit log shows the full journey: submitted → denied → submitted → paid

We intentionally don't short-circuit "denied → paid" — the audit trail wants to see the appeal step captured.

Denial rate as a signal

A denial rate above ~5% for an established practice usually indicates one of:

  • Coding errors (wrong CPT, missing modifier)
  • Eligibility issues (payer doesn't cover that code for that plan)
  • Documentation gaps (payer wants chart notes that weren't submitted)

Use the Analytics Insights panel to watch trend direction. A denial-rate spike for one provider or one CPT code is the fastest signal to act on.

If you hit a problem

  • Webhook stopped sending denials: check /admin/webhooks for the subscription + recent delivery log
  • Denial reason is too long for the field: truncate or abbreviate — free-text field caps at 2KB
  • Other: support@ralthealth.com