Prepared for a behavioral health and SUD network in Virginia · Multi-facility · Trailing 30 days
Source: Claim.MD ERA + AR aging exports
Engagement: rapid 3-day AR audit
This is a representative sample, not a real engagement. All names, payer behaviors, claim counts, and dollar amounts are synthetic but built to be internally consistent and recognizable to RCM, finance, and compliance professionals. A real engagement carries your data, your payers, and your service lines, with first findings delivered in under three days after receipt of core data.
A behavioral health network with four facilities and roughly 1,000 claims per month. Window: trailing 30 days. Numbers tie line-for-line to the ERA totals in the synthetic Payments / Adjustments dataset.
Adjudicated charges
$1,142,396
Across 1,063 claims · 6 primary payers
Denials beyond write-off
$319,447
28.0% of adjudicated · 9 reason categories
Recoverable now
$106,389
High-confidence appeal or resubmit
Net collection
64.3%
Of adjudicated charges
Of $1,142,396 in adjudicated charges, only 64.3% was paid. The rest is shown honestly. Normal write-offs and patient balances are not counted as losses.
Net of small payer recoupments of $5,765 in the window. Figures tie to the CARC totals in the ERA export. Components rounded; totals exact.
Total open AR: $3,268,100 across all payers and service lines. Aging shows time, not action. The next two sections separate stuck claims from normal payment lag.
0–30 days
$1,438,200
44.0% · normal lag
31–60 days
$681,200
20.8% · watchlist
61–90 days
$456,900
14.0% · stuck claim risk
91–120 days
$310,600
9.5% · timely filing alert
121–180 days
$258,400
7.9% · commercial deadline window
181+ days
$122,800
3.8% · Medicaid window only
$1.15M sits in the 61–180-day band. A material share of that balance is claims open at payer with no follow-up touch in 21+ days. The recovery queue ranks the highest-value items first.
CO-B7 ($125,520) means the rendering provider was not certified or enrolled with the payer for that service on that date. CO-256 ($18,618) is the contract-level twin. When a provider or location isn't active with a payer, every claim they send denies until the gap is closed. At this volume, the clinical work is being done; the dollars are being lost upstream.
Sorted by dollars, shown per month. Every category maps to a specific pre-submission control. Recoverability rated honestly.
| Category | CARC codes | Per month | Recoverability | How Adentris catches it |
|---|---|---|---|---|
| Credentialing / enrollment | CO-B7 · CO-256 | $144,138 | Prevent · partial retro | Provider-payer enrollment matrix checked pre-submit. Hold claim and route to enrollment if not active. |
| Authorization / precert | CO-197 · CO-39 · CO-198 · PR-243 | $81,524 | High | Flag auth-required services pre-submit; auto-build appeal for wrongly-denied auth-exempt crisis (H2011). |
| Duplicate submissions | OA-18 · CO-18 · PI-B13 | $47,144 | Rework only | Detect duplicate before send. Original usually paid; AR delay and rework disappear. |
| Coding | CO-4 · CO-189 · CO-151 · CO-97 | $12,531 | High | Modifier, units, NCCI, unlisted-code checks pre-submit. Map unlisted to payer-accepted HCPCS. |
| Documentation / info | CO-251 · CO-16 · CO-226 | $11,969 | High | Required attachment / documentation present and complete before submit. |
| Eligibility / COB | PR-27 · OA-23 · CO-109 · CO-22 | $7,847 | Partial | Eligibility and COB check at intake; route to correct payer or bill secondary. |
| Reconsideration upheld | CO-193 | $7,748 | Low | Hardest bucket. Track to closure; prevent root cause upstream so it never reaches appeal. |
| Timely filing | CO-29 | $6,312 | Lost · prevent forward | Per-payer filing clock with alerts before the window closes. These dollars gone; control stops the next ones. |
| Other / misc adjustments | CO-129 · CO-50 | $234 | Mixed | Small miscellaneous payer adjustments; monitored. |
| Total beyond write-off | $319,447 | Per month. Excludes contractual write-off ($82,170) and patient responsibility ($11,936). Components rounded; total exact. | ||
For your billing team: the specific failure, the regulation or coding rule it violates, and the pre-submission control that prevents it.
CO-B7 · CO-256
Claims billed under a rendering provider or location not yet active with that payer for the date of service. When clinician enrollment lags their start date, every claim in the gap denies.
Medicaid provider screening and enrollment under 42 CFR Part 455, Subpart E, and managed-care plan enrollment under 42 CFR 438.602(b). Payers do not pay for services dated before the credentialing effective date with that plan; each Cardinal Care MCO holds its own effective date.
Maintains a live provider-payer enrollment matrix (NPI × plan × effective date × service). Before a claim is built it checks rendering provider status with the destination payer for the DOS. If not active, holds the claim and routes to enrollment instead of letting it deny. Where retro-enrollment is allowed, flags the recoverable window.
CO-197 · CO-39 · CO-198
Auth-required services billed with no auth on file (CO-197), units exceeding what was authorized (CO-198), or denial at the time auth was requested (CO-39). In BH/SUD this hits residential, PHP and IOP hardest.
Each payer's prior-authorization policy; for SUD levels of care these track the ASAM Criteria for medical necessity, and Virginia Medicaid ARTS requires service authorization for higher levels of care. Note: crisis intervention (H2011) is commonly auth-exempt, so "no auth" denials on H2011 are often incorrect and appealable.
Flags every line that needs auth for that payer and level of care, checks valid auth (units and date span) is on file, and opens an auth task if not. For wrongly-denied auth-exempt services (the H2011 pattern at Aetna and Sentara) it assembles the appeal with the policy citation.
OA-18 · CO-18 · PI-B13
The same service was submitted twice and the payer denied the duplicate. The original usually already paid, so this isn't lost revenue, it's wasted rework and added A/R days from resubmitting instead of checking status.
Payer duplicate-claim logic and NCCI duplicate / frequency edits. A service already adjudicated denies as a duplicate (CO-18 / OA-18) or as previously paid (B13).
Before sending, checks claim history for matching prior submission (member, DOS, code, units, provider) and its status. If an original is pending or paid, suppresses the duplicate and surfaces the real action: check status, post payment, or appeal the original.
CO-4 · CO-189 · CO-151 · CO-97
Required modifier missing or inconsistent (CO-4); unlisted code billed where specific one exists (CO-189); units / frequency unsupported (CO-151); line bundled into another service (CO-97).
CPT / HCPCS modifier rules and the CMS National Correct Coding Initiative: Procedure-to-Procedure (PTP) edits for bundling (CO-97) and Medically Unlikely Edits (MUEs) for units (CO-151); payer policy requiring specific HCPCS over unlisted code (CO-189).
Runs the coded claim through modifier appropriateness, MUE unit limits, NCCI PTP bundling and unlisted-to-specific mapping before submission. For United's H0046 "unlisted" (CO-189) maps to the accepted code; where a PTP edit applies, checks the modifier is clinically justified before adding one.
Where collection is strong, where it is leaking, and where payer behavior is changing. Ranked by billed.
| Payer | Billed | Paid | Denied | Collection rate | Denial rate | Response p50 | Pattern |
|---|---|---|---|---|---|---|---|
| Sentara Health Plans | $384,210 | $222,841 | $84,526 | 58.0% | 22.0% | 38d | H2011 auth denials trending up |
| Anthem CCC Plus | $312,490 | $209,368 | $46,873 | 67.0% | 15.0% | 22d | Stable |
| Aetna Better Health | $267,140 | $189,669 | $32,057 | 71.0% | 12.0% | 18d | Records requests rising |
| United HC Community | $189,820 | $130,976 | $26,575 | 69.0% | 14.0% | 26d | H0046 unlisted mapping issue |
| Virginia Premier | $148,560 | $104,943 | $25,255 | 70.0% | 17.0% | 31d | Open-at-payer cluster, 47–62d |
| Optima Health | $98,420 | $73,815 | $14,762 | 75.0% | 15.0% | 19d | Underpayment vs. contract ~14% |
Concentration: Sentara represents 33.6% of billed and 26.5% of denied. Sentara behavior alone moves the network's collection rate by ~3 points. Single-payer trend monitoring recommended.
From a sample of 84 charts associated with denied claims. Patterns visible at this sample size are very likely systemic.
Notes describe service delivery without explicitly establishing why the level of care was medically necessary. Disproportionately concentrated in PHP and IOP level transitions.
Affects · CO-197, CO-251 denialsASAM dimensional findings not consistently tied to recommended level. Concurrent review records support level of care but the original admission note often does not.
Affects · auth and recoupment riskSignatures attached more than 72 hours after service or missing on group counseling notes. Creates evidentiary problems on appeal.
Affects · audit defensibilityBilled services not represented in the active treatment plan, or treatment plan not updated to reflect current level of care.
Affects · CO-226 denials, payer auditsContinued-stay reviews missing or not aligned to the payer's expected cadence. Higher exposure on residential stays beyond 14 days.
Affects · concurrent review denialsMissing or partial discharge summaries on closed episodes. Limits ability to defend the full episode and slows next-level handoffs.
Affects · payer post-pay reviewsA claim-level queue. Work these first. Full queue: 247 claims totaling $106,389 in high-confidence recoverable revenue.
Subtotal of top 8: $101,284 · 95.2% of high-confidence recoverable pool
Payer audit signals, SIU exposure, documentation defensibility issues, and recordkeeping gaps that require leadership attention.
In order of expected impact on the network's net collection rate over the next 90 days.
Stand up the provider-payer enrollment matrix. Hold claims pre-submit when provider is not active. Pursue retro-enrollment where the plan allows. This single action protects 30% of monthly denial exposure.
Auth-exempt under each payer's policy. Appeal package includes the policy citation and the chart evidence. Build the template once; reuse for future H2011 denials.
Update billing rules so that unlisted H0046 is replaced with the payer-accepted code before claim build. Resubmit the 31 affected claims with the correct coding.
Virginia Premier and Sentara claims sitting more than 21 days without touch. Status checks and structured escalation will move most without appeal. Build the SLA into the AR workflow.
14 of 84 sampled charts show weak medical necessity language. Targeted education at the two facilities driving the pattern, plus a documentation template aligned to ASAM dimensions. Lowers the next quarter's denial volume meaningfully.
The figures above are real 30-day numbers from the synthetic dataset. Projected across a year (monthly × 12, an assumption that one month is typical), denials beyond write-off run about $3.83M, with the high-confidence recoverable pool near $1.28M and credentialing alone close to $1.73M. A 12-month export would confirm whether this month is representative; we recommend pulling it before relying on the annual figure.