Denial Management Resources | Sirius Solutions Global

Denials rarely come from one cause. In our experience working claims across specialties, most denials trace back to one of four categories: eligibility and authorization issues caught too late, documentation gaps that don't support the billed code, coding inaccuracies including modifier misuse, and payer-specific bundling edits that change more often than most practices can track manually. The articles and resources below focus on those root causes rather than just appeals paperwork — because preventing a denial is consistently cheaper than fighting one after the fact.

Common Cause

Eligibility & authorization

Coverage lapses, plan changes, or missing/expired prior authorizations caught after the visit instead of before it.

Common Cause

Documentation gaps

Clinical notes that don't clearly support the medical necessity of the billed code or level of service.

Common Cause

Coding inaccuracies

Incorrect code selection, missing or misused modifiers (like 25 or 59), and mismatched diagnosis-to-procedure pairing.

Common Cause

Bundling & NCCI edits

Procedure combinations that payers bundle under National Correct Coding Initiative edits, which update regularly.

Denial Management Articles

Prior Authorization

Prior Authorization in 2026: What the New CMS Rule Actually Requires

Authorization-related denials are one of the biggest preventable categories — here's what changed under CMS-0057-F.

8 min read Read More

Denial Management

Denial Management Trends for 2026: Where Claims Are Actually Getting Stuck

In production — a full breakdown of 2026 denial-rate benchmarks by payer type, coming next.

Coming soon

Healthcare Technology

AI in Medical Billing and RCM: What's Actually Changing in 2026

Where AI is genuinely reducing denials today, including the gap between adoption hype and real denial-focused use.

9 min read Read More

Common Questions

Industry benchmarks generally treat an initial denial rate under roughly 5–10% as healthy, though the right target varies by specialty, payer mix, and claim complexity. What matters more than the exact number is tracking it consistently and knowing your top denial reason codes.

Both matter, but prevention has the better return. Rework and appeal costs per denied claim have been rising, so fixing the front-end causes — eligibility checks, authorization confirmation, documentation review — typically pays back faster than building a larger appeals process.

Pull your denial reason codes (CARC/RARC) over a rolling 90 days and group them by category rather than reading them one claim at a time. A pattern usually emerges quickly — most practices find 3–4 reason codes account for the majority of denied dollars.

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