Stop denial rework with root cause analysis
Distinguish claim denial symptoms from root causes and define a corrective action that prevents recurrence.
The move: write the process cause, not just the denial reason. Root cause analysis asks what set the defect in motion and what control failed to catch it. In health insurance operations, this keeps a team from treating every denied claim as a one-off correction. Symptom The claim denied for no authorization, invalid member eligibility, coordination of benefits, duplicate claim, or noncovered service. The symptom tells you what happened at adjudication. Process condition The process condition explains why the claim reached adjudication that way. Examples: an auth feed dropped records with provider mismatch, an employer file arrived after the claims…
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