Denial Workbench

The Denial Workbench is your central tool for tracking, managing, and resolving denied claims. It pulls information from ERA (835) files and allows your team to organize denial work items, track appeal progress, and measure recovery outcomes.

Navigate here from the left menu: Denial Workbench.

Note: You must have the DenialWorkbench role assigned to access this feature. Contact your administrator if you don't see it in the menu.

The Denial Workbench has two main views:

• Queue — a searchable, filterable list of all denial work items for your account
• Detail — a deep-dive into a single denial with timeline, notes, appeals, supporting documents, status management, and resolution tracking

Additional pages:

• Appeal Wizard — a 4-step guided workflow for building and submitting appeals
• Timely Filing Letter — a dedicated single-page screen for building a timely-filing appeal from your submission history
• Appeal Templates — manage reusable letter templates and CMS appeal forms

Access to the Denial Workbench is controlled by three permission scopes:

All three denial scopes are included in the DenialWorkbench role. The admin scope requires the Admin role.

The queue is the landing page when you navigate to the Denial Workbench. It shows all denial work items for your account.

At the top of the page, five summary cards show key metrics at a glance:

Use the filter bar to narrow your results. Click the toggle button to expand or collapse the filters.

• Status — filter by work item status (Intake, InReview, AppealInProgress, etc.)
• Priority — filter by priority level (Low, Medium, High, Critical)
• Category — filter by denial category (Eligibility, Coding, NonCovered, etc.)
• Payer — search by payer name
• Assigned To — filter by who the item is assigned to
• Date Range — filter by date the denial was created

Click Search to apply filters, or Clear to reset all filters.

The results table shows each denial work item with the following columns:

Select multiple items using the checkboxes, then use the bulk action bar to:

• Bulk Assign — assign all selected items to a team member
• Bulk Change Priority — update the priority of all selected items
• Batch Appeal — generate and submit appeals for all selected items at once (see Batch Appeals below)

Click the Templates button in the queue header to go to the Appeal Template Management page.

Click any work item in the queue to open its detail view. The detail page has a two-column layout.

Shows the key information about the denied claim:

• Patient Name, Claim Number, Payer, Provider
• Billed Amount, Paid Amount, Denied Amount — displayed in color-coded boxes
• CARC Codes — the Claim Adjustment Reason Codes with color-coded chips
• RARC Codes — Remittance Advice Remark Codes (if present)
• Category Explanation — a description of the denial category
• ERA Classification — the automatic classification assigned during ERA processing

The Timeline card has two tabs. Both pull from every version of the claim — when a claim is corrected and resubmitted, each revision lives as a separate document, and the timeline now walks all of them so every submission attempt shows up. Each tab has its own Export CSV button (top-right of the tab) for offline analysis. Both tab bodies are scrollable when they grow long.

A vertical timeline showing every event tied to this work item:

• Claim Submitted — when the original claim was sent
• Clearinghouse Acknowledgement — accepted or rejected by the clearinghouse (999 / 277CA)
• Payer 277 Response — payer status responses with category and status codes
• ERA Received — when the payment/denial arrived
• Claim Edited — any edits made in the claim editor
• Rebilled — when a corrected version was created
• Notes — notes added by team members
• Status Changes — every status transition

Each event shows the date, description, and the user who performed the action.

A filtered, evidence-focused view showing only the events that prove timely submission — submissions, clearinghouse acks, 277 responses, and ERAs — across every revision of this claim. Each row shows:

• Date (YYYY-MM-DD) and a short summary
• ICN — ISA control number from the EDI envelope
• GS — Functional group control number
• ST — Transaction set control number
• BHT — Beginning of Hierarchical Transaction control number
• Charge — billed amount on the claim at time of submission
• Paid — amount paid on any ERA event
• Category : Status — 277 reject codes when present
• Reject reason — the payer's free-form text on 277 rejections

The Generate Timely Filing Letter button at the top of the Filing tab takes you to the dedicated Timely Filing Letter screen.

The Appeals card shows all appeal submissions for this work item. Each appeal entry displays:

• Appeal Level — the Medicare appeal level (see Appeal Levels below)
• Submitted Date — when the appeal was filed
• Deadline — the deadline for payer response
• Outcome — color-coded status:
  • Pending (orange) — awaiting payer decision
  • Won (green) — payer reversed the denial
  • Lost (red) — appeal was denied
  • Withdrawn (gray) — appeal was withdrawn
• Amount Recovered — dollar amount recovered (shown when the appeal was won)
• Outcome Notes — notes about the payer's response
• Download Packet — if an appeal packet was generated, a download link appears to retrieve the ZIP file

Start New Appeal — click this button to launch the Appeal Wizard for this work item.

Record Outcome — for pending appeals, click Record Outcome to open an inline form where you can:

• Select the outcome: Won, Lost, or Withdrawn
• Enter the outcome date
• Add outcome notes (e.g., payer reference number, reason for decision)
• Enter the recovered amount (if Won)

When you record an outcome of “Won,” the work item status is automatically updated to AppealWon. A “Lost” outcome updates the status to AppealLost.

The Supporting Documents card lets you manage files attached to the work item (medical records, EOBs, clinical notes, etc.):

• Upload — click Select Files to choose one or more files from your computer, then click Upload to save them to the work item
• Download — click the download icon next to any document to retrieve it
• Delete — click the delete icon to remove a document from the work item

Uploaded documents are stored securely in Google Cloud Storage and are available to include in appeal packets. Multi-file upload is supported — select multiple files at once and they will be uploaded sequentially.

Tip: Upload all supporting documentation (medical records, authorization letters, clinical notes) to the work item before starting an appeal. The Appeal Wizard and Appeal Packet features pull documents from here.

View existing notes and add new ones. Each note includes:

• Note Type — General, PhoneCall, Research, AppealPrep, PayerContact, or Escalation
• Action Taken — what was done
• Finding — what was discovered
• Next Step — what should happen next
• Free Text — any additional details

Shows the current state of the work item:

• Status — current workflow status with a color-coded chip
• Priority — current priority level
• Assigned To — who is responsible
• Days Open — how long the item has been open
• Due Date — timely filing deadline with a warning if approaching or overdue

Important: A timely filing alert appears when the due date is approaching (orange warning) or has passed (red alert). Missing timely filing deadlines can result in permanent loss of appeal rights.

• Change Status — update the work item status (Intake, InReview, AppealInProgress, AppealSubmitted, AppealWon, AppealLost, WrittenOff, Rebilled, Paid, Closed)
• Assign — assign or reassign the work item to a team member
• Set Priority — change the priority level (Low, Medium, High, Critical)
• Resolve — close the work item with a resolution type:
  • Appeal — selecting this option redirects you to the Appeal Wizard to start the formal appeal process
  • WriteOff — denial was written off
  • Rebill — claim was corrected and rebilled
  • Patient Responsibility — balance transferred to patient
• Delete Work Item — permanently removes the work item. Use this to clean up duplicates or items created in error. You'll be prompted to confirm before the delete runs; afterwards you're returned to the queue.

Once a work item is resolved, a resolution card appears showing:

• Resolution Type — how it was resolved
• Reason — why this resolution was chosen
• Amount — the dollar amount resolved (if applicable)
• Resolved Date — when it was resolved
• Resolved By — who resolved it

The Denial Workbench supports the full 5-level Medicare appeal process. These levels are available throughout the system — in the Appeal Wizard, batch appeals, and appeal templates.

• Level 1 — Redetermination is the first step. The Medicare Administrative Contractor (MAC) reviews the claim again.
• Level 2 — Reconsideration is reviewed by an independent Qualified Independent Contractor (QIC).
• Level 3 — ALJ Hearing is heard by an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA). Requires a minimum amount in controversy.
• Level 4 — Appeals Council is reviewed by the Departmental Appeals Board (DAB). This level reviews whether the ALJ applied the law correctly.
• Level 5 — Judicial Review is filed in Federal District Court. This is rarely used and has a higher amount in controversy threshold.

Tip: Most denials are resolved at Level 1 or Level 2. Levels 4 and 5 are uncommon and typically only apply to Medicare claims.

The Appeal Wizard guides you through a 4-step process to create and submit an appeal for a denied claim. Launch it from the detail page by clicking Start New Appeal in the Appeals card, or by selecting Appeal as the resolution type.

Note: For timely-filing denials (CARC CO-29), use the dedicated Timely Filing Letter screen instead — it skips the level/template selection and pre-populates the letter from your submission history.

Review the claim information and configure the appeal:

• Claim Summary — patient name, claim number, payer, denial reason codes, and amounts (read-only)
• Appeal Level — select the appeal level (1 through 5, see Appeal Levels above)
• Previous Appeals — if appeals have been submitted before, they are listed here with their outcomes
• Payer Appeal Information — if available, shows:
  • Filing deadline (calculated from payer contract)
  • Payer appeal mailing address
  • Payer fax number
  • Payer portal URL
  • Payer phone number
• Required Forms — if CMS appeal forms have been uploaded for the selected appeal level (see CMS Appeal Forms), they appear here with download buttons. Download and complete these forms to include with your mailing.

Tip: The required forms section updates automatically when you change the appeal level. Make sure to download the correct forms before proceeding.

Build the appeal letter:

• Template Selector — choose from saved templates filtered by payer and appeal level. Templates are pre-populated with claim data (patient name, dates, amounts, etc.)
• Letter Body — an editable text area with the appeal letter text. The letter is pre-populated from the selected template with all placeholders replaced with actual claim data
• Save as Template — save the current letter as a reusable template for future appeals
• Generate PDF Preview — create a PDF version of the letter for review. A download link appears when the PDF is ready

When you change the appeal level or select a different template, the letter is automatically regenerated with the updated information.

Manage the supporting documents attached to this work item (this step is optional):

• Existing Documents — view all documents currently attached to the work item, with file name, size, and download/delete buttons
• Upload Files — click Select Files to choose files from your computer, then click Upload to add them to the work item
• Multi-file upload is supported — select multiple files at once

Documents uploaded here are stored on the work item itself, so they are visible on the detail page and available for inclusion in appeal packets.

Review everything before submitting:

• Appeal Level — confirms the selected level
• Deadline — the filing deadline
• Submission Method — choose how the appeal will be sent: Mail, Fax, Portal, or Phone
• Letter Preview — scrollable preview of the final letter text
• Supporting Documents — count of attached documents

Click Submit Appeal to file the appeal. The system will:

• Create an appeal record on the work item
• Update the work item status to AppealSubmitted
• Add a timeline event recording the submission

After submitting, the Appeal Packet section appears:

• Generate Appeal Packet — creates a ZIP file containing:
  • The appeal letter as a PDF
  • All supporting documents uploaded to the work item
  • Any CMS forms configured for the appeal level
• Download Packet — downloads the generated ZIP file

The packet is designed for mailing — print the contents and send to the payer's appeal address.

Click Done — Return to Work Item to go back to the detail page.

The Timely Filing Letter screen builds a provider-attested appeal letter that embeds ClaimRev's record of every submission attempt as evidence. Use it when a payer denies for timely filing (most commonly CARC CO-29 — “The time limit for filing has expired”) and you can show the claim was submitted on time.

Launch it from the work item detail page → Timeline card → Filing tab → Generate Timely Filing Letter.

The screen is a single scrollable page (no wizard, no level selector — timely filing is always the initial appeal). It contains four cards stacked top-to-bottom:

Read-only summary of the claim: patient, payer, service date, denied amount.

An editable letter body, pre-populated with:

• Today's date
• Payer appeals address salutation
• Patient + claim identifiers
• Submission timeline — a numbered list of every submission attempt across every revision of the claim, with the full set of EDI control numbers (ICN, GS, ST, BHT), charge amount, clearinghouse ack outcome, 277 status codes/reasons, and any ERAs received

The letter draws from a default in-code template. If you've created an Appeal Template named exactly “Timely Filing Appeal” with payer “Default”, that template is used instead — see Appeal Template Management.

Generate PDF Preview — top-right button. Renders the current letter body to PDF and shows a confirmation when it's ready.

Same upload/download/delete behavior as the work item detail's Supporting Documents card. Anything attached here is included in the final appeal packet.

• Submission Method — Mail / Fax / Portal / Phone
• Deadline — pre-filled from the payer's filing deadline when known
• Submit Appeal — files the appeal at Level 1 and updates the work item status to AppealSubmitted

After submitting, you can generate and download an Appeal Packet ZIP just like in the regular Appeal Wizard.

Tip: Edit the letter freely before submitting. The pre-populated submission timeline is the evidence portion of the letter — review it for accuracy (e.g., make sure all 277 reject reasons are payer-side, not your-side errors that you've since corrected).

If you create a custom Appeal Template named “Timely Filing Appeal”, use the {{SubmissionTimeline}} placeholder anywhere in the letter body — it will be replaced with the numbered submission history.

CMS appeal forms are blank forms required by Medicare and other payers at specific appeal levels (e.g., CMS-20027 for Redeterminations). Administrators can upload these forms so billers can download them during the appeal process.

Navigate to Denial Workbench → Templates and scroll down to the CMS Appeal Forms section.

• Upload Form — click this button to open the upload form:
  • Form Name — the form identifier (e.g., “CMS-20027”)
  • Appeal Level — which appeal level this form is for (1-5)
  • Payer Type — Medicare, Commercial, or All
  • Description — a description of the form (e.g., “Medicare Redetermination Request Form”)
  • File — select the form file (PDF, DOCX, etc.)
• Uploaded Forms — lists all uploaded forms with level, payer type, description, file size, and download/delete buttons

• In the Appeal Wizard Step 1, when a biller selects an appeal level, any forms uploaded for that level appear in a “Required Forms” section with download buttons
• In the Appeal Packet (Step 4), CMS forms for the appeal level are automatically included in the ZIP download under a cms_forms/ folder
• Forms are available to all users with denial:read permission; only admins (admin:claimmgmt) can upload or delete them

Tip: Upload the standard CMS forms for each Medicare appeal level so your team always has the correct forms at their fingertips. Common forms include CMS-20027 (Redetermination), CMS-20033 (Reconsideration), and the OMHA-100 (ALJ Hearing Request).

Navigate to Denial Workbench → Templates to manage reusable appeal letter templates.

The template list shows all saved templates with:

Click New Template or the edit icon on an existing template to open the form:

• Payer Name — enter the payer name this template is for, or “Default” to create a catch-all template used when no payer-specific template exists
• Appeal Level — Level 1 through 5 (see Appeal Levels)
• Template Name — a descriptive name for the template
• Submission Method — the default submission method
• Letter Body — the template text. Use placeholders that will be replaced with claim data when the template is used in the Appeal Wizard
• Internal Notes — notes visible only to your team (not included in the letter)

Special case: To customize the Timely Filing letter for your account, create a template named exactly “Timely Filing Appeal” with PayerName “Default” and Level 1. The Timely Filing Letter screen will use it instead of the built-in default.

Use these placeholders in the letter body. They will be automatically replaced with actual claim data:

Tip: Create templates for your most common payer/level combinations. When no exact match is found, the system falls back to a “Default” template for that appeal level.

When multiple denials from the same payer need to be appealed, you can use Batch Appeal to generate and submit appeals for all of them at once.

1. In the Denial Queue, select two or more work items using the checkboxes
2. Click the Batch Appeal button in the bulk actions bar
3. A panel appears with:
   • Appeal Level — choose the appeal level (1 through 5) for all selected items
   • Template — select the letter template to use (templates are loaded from your saved templates)
   • Item Count — shows how many items will be appealed
4. Click Generate & Submit Appeals

The system will:

• Generate an appeal letter for each selected work item using the chosen template
• Replace all placeholders with each item's specific claim data
• Create a PDF for each appeal letter
• Bundle all PDFs into a ZIP file and save it to cloud storage
• Submit an appeal record for each work item
• Update each work item's status to AppealSubmitted

When complete, you'll see a summary showing how many appeals succeeded and how many failed (with reasons).

Important: Batch appeals use the same template for all selected items. Make sure the selected items are appropriate for the same appeal level and template. For customized letters, use the Appeal Wizard for each item individually.

There are two ways claims can be added to the Denial Workbench:

When reviewing ERA payment information, you can manually add a claim to the workbench:

1. Navigate to Payment Advice (ERA) and search for the claim
2. Click the gavel icon on the claim row to open the ERA Actions menu
3. Select Add to Denial Workbench

This menu also includes:

• Test Classification — test the ERA classification rules without saving
• Classify & Save — run classification and save the result

The same ERA Actions menu is available in the Payment Advices tab when viewing claim details.

Duplicate detection: “Add to Denial Workbench” is idempotent — if the same ERA has already been pulled for your account, no duplicate is created and the snack message reads “Already in Denial Workbench” instead of “Added to Denial Workbench”. The work item retains its prior notes, status, and history.

When enabled, the system automatically creates denial work items based on ERA classification rules. This is configured per account in the admin settings.

When auto-add is active:

• ERA files are automatically classified as they are received
• Claims matching denial rules (e.g., CARC code 4 with CO group code and $0 paid) are automatically added to the workbench
• Priority is set based on the matching classification rule

The Denial Workbench uses classification rules to categorize ERA payments. Each rule checks:

• Group Codes — the claim adjustment group (CO, PR, OA, PI, CR)
• CARC Codes — specific reason codes to match
• Exclude CARC Codes — reason codes that should not match
• Condition — payment conditions (Paid Zero, Paid Not Zero, Underpaid, Paid Negative)
• Min Dollar Amount — minimum denied amount to trigger the rule
• Result Classification — the category to assign (Denied, PartiallyDenied, Pending, etc.)
• Auto-Add to Workbench — whether matching claims should be added automatically
• Priority — the priority level for auto-added items

The system comes with built-in default classification rules:

Accounts can use the default rules or customize their own through the admin configuration page.

Administrators can configure the Denial Workbench per account under Admin → Denial Workbench Configuration.

1. Enter the Account Number and click Load Config
2. Configure Global Settings:
   • Auto-add to workbench — enable/disable automatic creation of denial work items
   • Use default classification rules — use the built-in rules (recommended for most accounts)
3. If using custom rules, uncheck “Use default classification rules” to reveal the editable rules table
4. Click Save Configuration to save your changes

Tip: Most accounts should use the default classification rules. Only customize rules if you need account-specific behavior (e.g., different dollar thresholds or additional CARC codes).

• Triage daily — review new items in “Intake” status each morning and assign them to team members
• Set priorities — use Critical for high-dollar denials approaching timely filing deadlines
• Add notes — document every phone call, research finding, and next step so anyone can pick up the work
• Track timely filing — the due date alerts help prevent missed appeal deadlines
• Use bulk actions — when a batch of denials from the same payer arrives, bulk-assign them to the specialist for that payer
• Set up templates early — create appeal letter templates for your most common payers and denial types before you need them. This speeds up the appeal process significantly.
• Upload CMS forms — have your admin upload the required CMS forms for each appeal level so they're always available in the wizard and included in appeal packets automatically
• Upload documents first — attach medical records, EOBs, and clinical notes to the work item before starting an appeal. This ensures they are available in the wizard and included in the appeal packet.
• Use batch appeals for volume — when multiple denials from the same payer need the same type of appeal, use Batch Appeal to process them all at once
• For CO-29 (timely filing) denials, use the Timely Filing Letter screen — it builds a provider-attested letter that embeds your full submission history (with EDI control numbers) as evidence. Skip the wizard.
• Export the Filing Timeline as CSV — when reconciling against a payer's intake logs, the CSV gives you ICN/GS/ST/BHT for every submission attempt in a format you can hand off to the payer or paste into a spreadsheet
• Record outcomes promptly — when you receive a payer response, record the outcome immediately so your stats and recovered amounts stay accurate
• Escalate through levels — if a Level 1 Redetermination is denied, use the Appeal Wizard to file a Level 2 Reconsideration. The system tracks all 5 levels for each work item.
• Use appeal packets — after submitting an appeal, generate the appeal packet ZIP to get everything (letter, documents, forms) bundled for mailing
• Resolve promptly — mark items as resolved as soon as the outcome is known to keep your queue accurate
• Delete duplicates — if you ever spot two work items for the same ERA (rare; duplicate detection prevents new ones), use the Delete Work Item button on the wrong one to clean it up

See also: How to Upload Claim Files | Claim Search

Need help? Contact ClaimRev support at help@claimrev.com or call 918-842-9564.