denial-prevention-and-appeals

name	denial-prevention-and-appeals
description	Prevent PT/rehab claim denials at the front end (eligibility, authorization, units, modifiers, documentation) and triage the ones that slip through to their root cause, then write a documentation-grounded appeal — confirming each payor's edits before billing.

Denial Prevention & Appeals

A denial is the expensive recovery of a front-end miss. Prevent first; appeal with evidence.

Front-end prevention (before the claim leaves)

1. Eligibility + benefits verified — active coverage, therapy benefit, visit cap.
2. Authorization in hand if required, with enough visits.
3. Units correct under the 8-minute rule (see ../therapy-billing-and-units/SKILL.md).
4. Modifiers correct (GP/KX/59) and supported by documentation.
5. Documentation establishes medical necessity and skilled care (see ../defensible-documentation/SKILL.md).

Denial triage (root cause → fix)

Denial signal	Likely root cause	Fix
Units / frequency	8-minute-rule variant, cap exceeded	Recount; check payor variant + auth
Modifier / NCCI edit	Missing/wrong GP/KX/59	Match modifier to discipline/threshold/distinct service
Medical necessity	Boilerplate / no skilled justification	Documentation, not appeal language, is the fix
Eligibility / auth	Front-end miss	Verify before re-submission

The appeal

Lead with the documentation that already exists — the note is the evidence. Cite the specific clinical reasoning, the POC goal, and (if threshold) the KX attestation basis. A late or boilerplate appeal loses.

Verify-at-use

• Each payor's denial reason codes, edits, and appeal windows differ and change — confirm against the payor's current policy before re-billing or appealing. [verify-at-use].

Traverse the denial-triage tree in ../../knowledge/pt-clinic-decision-trees.md; template at ../../templates/denial-appeal-letter.md.