The denial rate measures how often payers refuse to pay claims as submitted. It can be calculated by claim count or by dollar value, and is most useful broken down by reason code, payer and provider.
Most denials trace back to preventable front-end problems such as eligibility, authorization, registration and coding errors.
Formula
Denial rate = claims denied ÷ total claims submitted × 100 (for a period)
Related terms
- Claim denial
- A payer's decision not to pay a claim that it received and processed.
- CARC (claim adjustment reason code)
- The standard code that explains why a claim line was paid differently than billed.
- Clean claim rate
- The share of claims that pass all edits and are accepted on the first submission.