Billing and claims
Denials and appeals
Read the Denial Management Dashboard, understand top denial reasons and payer performance, and create an appeal with a drafted narrative and letter you review before it is sent.
The dashboard
Billing > Denials shows, for the last 30 or 90 days, six months, or a year: Denial Rate, Total Denied Amount (revenue at risk), Appeal Success Rate, Recovered Amount, the Top Denial Reasons by category and count, and Payer Performance. Each denied claim lists its appeal deadline.
Creating an appeal
Create Appeal on a denied claim opens the appeal flow:
- Appeal settings: level and deadline.
- Appeal narrative: Sefton prepares the appeal reason from the denial code; you add clinical justification (guidelines, literature, notes) and authorization justification (numbers, exceptions) plus any additional information.
- Appeal Letter: the full letter for review before submission.
- Submit (electronically where the payer supports it, otherwise download and send). Status moves through Draft, In Progress, Submitted, In Review, Approved, Denied, Lost, or Withdrawn.
Denial prevention
Denial Recommendations and the Claims Audit Engine flag patterns before submission: a payer that denies a modifier combination, a code that needs authorization, a diagnosis that does not support the procedure. Fixing the pattern in Payer rules stops the denial recurring.
Appeals page
Billing > Appeals lists every appeal with claim, patient, amount, and status, plus success metrics.
Frequently asked questions
Does Sefton send the appeal by itself?
No. It drafts the narrative and the letter from the denial, the note, and the authorization. You review, edit, and send.