Denial evidence for health plans

Denial evidence is the file a health plan can produce to show why a requested or rendered service was not covered. It is the rule, the facts the reviewer had, the person who decided, and the notice that told the member or the provider. It is not a slogan, a remittance code, or a story about how much money a denial saved. Health plans and Medicaid and Medicare Advantage managed care organizations are the audience for this page.

What the file looks like before anyone asks for it

The denial is a code on a remittance. The reviewer who decided is no longer on the team. The notice is a portal screenshot that does not say which rule fired. The chart is at the hospital and the plan has a checkbox. When the letter comes, someone writes the reason that week.

Those are the signs.

A denial is a coverage determination

A utilization management denial says the plan will not authorize, or will not pay for, a service under the benefit and the criteria that apply. It is not a medical order, and it is not a statement that nobody should deliver the care. Members and physicians still decide what treatment to pursue. The plan decides what it will cover. Those are different acts. The file is about the second one, and it should never be written as if the plan had practiced medicine by declining payment.

Plans make that coverage decision at three moments: before the service, which is prior authorization; during the service, which is concurrent review; and after the service, which is retrospective review. The overview of those moments is what utilization management is. Denial evidence is the record of whichever moment it was, kept so a second person can see the same materials the first person used. If the second person cannot see them, the plan does not have evidence. It has a conclusion.

Four things the file has to show

First, the rule. Name the benefit provision, the state or federal policy, the plan medical policy, or the clinical criteria set, and keep the version that was in effect on the decision date. A denial that cannot name its rule cannot be appealed against its rule. The member-facing version of that problem is CARC and RARC codes. A code can tell you the category, such as medical necessity or a missing authorization. It does not tell you the criterion inside the category.

Second, the facts. The documents the reviewer actually used have to be the documents in the file. A paraphrase in a workqueue is not the operative report, the imaging result, or the therapy log. Why the clinical record has to travel is that requirement in full. The short version is that a rule with no facts is not an application of the rule. It is a label.

Third, the person. The determination is made by a qualified reviewer, not by a language model and not by the evidence software. Where the line of business expects a physician, including when Medicare Advantage bases an adverse organization determination on medical necessity, the file names that physician and the credential. AVA can compare a record to a cited guideline and draft words for a human to review. AVA does not decide the denial. The boundary is written out in what AVA can and cannot do.

Fourth, the notice and what followed. The letter or electronic notice, the date, the reason as stated to the member or the provider, and the appeal path printed on it. Later documents, a peer-to-peer discussion, and the appeal decision are added in order. They do not overwrite the original determination. An appeal file versus a note is the difference between that stack and a single line in a queue.

Two files people confuse with this one

A remittance advice is not denial evidence. An electronic remittance and its reason codes classify how a claim line was adjusted and who bears the adjustment. That classification is necessary for payment. It is not the clinical criteria, the reviewer, or the notice of an adverse determination. A plan that can produce the code and cannot produce the review has not produced the utilization management file. Providers see this every week: the code arrives, the criterion does not, and the appeal has to begin by asking for the plan's own rule.

A payment-integrity file is not the same object either, even though it belongs to the same company. JIL Sovereign Technologies, Inc. publishes four evidence formats. CREB, the Court Ready Evidence Bundle, is the file built so counsel can offer what was decided and how it was kept. On this host that bundle is the utilization management history, the CREB described in what a CREB bundle is. AREB, the Audit Ready Evidence Bundle, is the provider-side payment-integrity format. PIEB, the Payer Integrity Evidence Bundle, is the payer-facing payment-integrity format. RREB, the Risk and Recovery Evidence Bundle, carries risk adjustment, including RADV, and recovery. The RADV and SIU product lives at jilsovereign.com. Use that site for those searches. Use https://insuredaudit.com for the utilization management denial record. The formats are one company's. The questions are not interchangeable. Neither website decides whether a tribunal will admit what counsel offers.

The files plans most often cannot reconstruct

Prior authorization at least begins with a request, so a packet often exists. Concurrent review is a series of short decisions during a stay, and the packet is whatever the reviewer saved that day. What belongs in a concurrent review record is the list: the span, the level of care, that day's documents, that day's criteria edition, the reviewer, the next review date, and the notice. A stay without that stack is a length-of-stay number. The number is not the evidence.

Medicaid adds eligibility on the relevant date, the state or contract rule, the EPSDT question for a member under 21, and a notice that preserves the appeal and fair-hearing path the program actually uses. What a Medicaid prior authorization record has to show is that file. Medicare Advantage uses a different appeal path and a Medicare benefit. The evidence rule does not change when the logo changes. The program named in the file has to be the program whose rule was applied, and the notice has to be the notice that was sent.

What the evidence is for, and what it is not

Denial evidence is how the plan answers an appeal, an external review, a fair hearing, a market-conduct exam, an external quality review, or a program audit without rebuilding the case from memory. What the examiner receives is the same stack described from the reader's chair. A CREB™ export packages the stack with a manifest and a tamper-evident chain so the reader can see what was included and can check that the export matches what was stored. The chain, in plain language, is hash chains and chain of custody. CourtChain™ is that custody record. It is not the Layer-1, and it is not a wallet.

None of this is a recovery forecast, a denial rate, or a result for a named customer. InsuredAudit does not publish someone else's overturns as if they were yours, and it does not invent a dollar figure for a file that has not been built. It is software a plan runs in its own environment, not a contingency collector and not a percentage-of-recovery vendor. It does not make the clinical decision. It keeps the decision legible enough that counsel can offer the file. The tribunal, not the software, decides what the file is worth and whether to receive it.

Questions people ask

What is denial evidence?

It is the file that shows why a requested or rendered service was not authorized or not paid under the benefit and the criteria that applied. The file contains the rule, the documents the reviewer used, the reviewer's identity and credential, and the notice. A slogan that the service was unnecessary is not the file.

Is a CARC or RARC code the denial evidence?

No. Those codes classify an adjustment on a remittance. They can name a category, such as medical necessity or a missing authorization. They do not identify the clinical criterion, the edition, the document, or the reviewer. The plan still has to produce that underlying file.

Who decides the denial?

A qualified reviewer working under the plan's criteria and the program's rules. InsuredAudit does not decide medical necessity. AVA can explain a denial, compare a record to a cited guideline, and draft language for a person to review. AVA does not decide the denial and does not file an appeal on its own.

Are CREB, AREB, PIEB, and RREB the same file?

They are evidence formats of the same company, JIL Sovereign Technologies, Inc., used for different questions. On this site the utilization management file is the coverage decision, packaged so counsel can offer it. AREB, PIEB, and RREB address payment integrity, including provider-side audit readiness, payer integrity, and risk adjustment and recovery. RADV and SIU searches belong on jilsovereign.com.

Does a complete file mean the denial will be upheld?

No. A complete file can document a denial that an appeal later changes, and it can document a denial that holds. Completeness makes those outcomes readable. It does not predict them, and it does not decide whether any tribunal will admit the file.