Not every denial needs a physician.
Routine billing, eligibility, missing-information, and modifier denials should stay with your internal team. Clinovian is for cases where the outcome turns on clinical reasoning, criteria interpretation, documentation adequacy, or payer medical-necessity logic.
A case is likely suitable if at least one applies:
Inpatient vs. observation dispute
Level-of-care determination where the payer downgrades admission status.
SNF / IRF / LTACH / home health denial
Post-acute prior-authorization or continued-stay denial.
DRG downgrade
Paid-but-downgraded claim requiring clinical-coding crossover reasoning.
Medical-necessity denial despite documented severity
The clinical facts support necessity, but the appeal needs criteria-mapped physician reasoning.
Failed-conservative-therapy dispute
Payer requires proof of exhausted conservative options before approving the service.
Payer-policy conflict
Internal payer criteria conflict with published standards or Medicare guidance.
High-dollar prior-auth denial
Complex PA denial where the clinical argument exceeds coder-level reasoning.
Complex comorbidity argument
Severity criteria hinge on cumulative comorbidity impact across organ systems.
P2P preparation needed
Scheduled peer-to-peer call with a payer medical director requiring criteria-mapped briefing.
Clinically differentiated Federal IDR dispute
Patient acuity, service complexity, provider qualifications, or facility circumstances require physician-level evidence mapping. Client retains filing and offer control.
A case is likely unsuitable if it is only:
Missing authorization number
Administrative, not clinical. Better handled within your standard billing workflow.
Eligibility or coordination-of-benefits issue
No clinical reasoning component. Not what the desk is built for.
Coding / modifier issue with no clinical dimension
A coding fix, not a medical-necessity argument. Better handled within your standard coding workflow.
Missing medical record (administrative)
The fix is submitting the record, not constructing a clinical argument.
Low-dollar routine denial
Below the complexity and value threshold where physician reasoning changes the outcome.
No clinical basis for appeal
The denial is correct. Clinovian does not manufacture medical necessity that the clinical facts do not support.
IDR filing, eligibility, coding, or offer-only request
Clinovian supplies the clinical evidence layer. Portal administration, eligibility, coding validation, offer selection, fees, and legal strategy stay with the client.
We do not manufacture medical necessity that the facts do not support.
This is not a limitation — it is why the desk's work product is credible. Selectivity is what keeps the output physician-grade. Every case we decline on clinical grounds protects the quality of every case we accept.
AI-drafted appeals needing clinical validation are suitable.
If your team uses AI tools to draft appeals, Clinovian provides independent clinical QA before submission — checking for hallucinated claims, weak criteria logic, missing comorbidities, and overstatement risk. This is a distinct sub-offer: see AI Appeal Clinical QA.
Not sure if your case qualifies?
Prospective clients may submit one de-identified matter for an initial fit assessment. Scope response in 24–48 hours.