Claim denial cost estimator for RCM

Measure the financial impact of denied claims and manual rework on your revenue cycle.

Where the claims are paid

Sets the currency, the payers' deadlines and the published rates. Offshore teams working US claims pick the US.

Monthly claim volume (claims)

Average claim value (USD)

Denial rate (% of claims)

The share denied on first submission; the result compares it with published rates.

Rework cost per claim (USD)

MGMA's average for medical practices is $25.20. Hospitals report $43.84 a claim to fight private payers' denials (Premier).

Denied value paid in the end (%)

After correction or appeal. 100% treats every denial as paid in the end, as the headline does. Published: 54.3% for hospitals' denials from private payers (Premier, 2022 claims).

Total monthly financial impact

$275,000

Show the working

10,000 claims × 10% = 1,000 denied. 1,000 × $250 + 1,000 × $25 = $275,000

Claim volume, denial rate, claim value and rework cost are your inputs.

1,000 of 10,000 claims a month denied, at 10%.

Value tied up in denials: $250,000
Administrative rework cost: $25,000
Lost for good a month: $25,000; The rework alone, with every denial paid

Paid after rework $250,000
Written off $0
Rework $25,000

1,000 denied claims a month is about 46 to work every working day. Until they're paid they hold up $250,000, and working them costs $25,000 a month.

If every denial is paid in the end, the money comes late rather than never, and the rework is the cost: $300,000 a year. Enter the share you're really paid to count the write-offs.

This represents the cash flow delayed by errors and the direct labour cost required to resubmit them.

Your denial rate against published rates
Whose claims	Denial rate
Yours	10%
Single-specialty practices (MGMA, 2023)	8%
Hospitals, private payers (Premier, 2022)	about 15%
HealthCare.gov plans (KFF, 2024)	19%

Each point of denial rate is 100 claims a month, $25,000 held up and $2,500 lost for good: the monthly figure to set against what preventing them would cost.

What fewer denials would keep
Denial rate	Monthly impact	Kept a year
10%, yours	$275,000
9%	$247,500	$30,000
7.5%	$206,250	$75,000
5%	$137,500	$150,000

Kept a year is the rework and write-offs each lower rate avoids. The rest of the drop in monthly impact is cash paid sooner rather than kept.

Working a denial pays when the claim is worth more than $25, the rework cost divided by the share paid in the end.

The clock in the United States

The clock starts at the denial notice. Medicare allows 120 days to ask for a redetermination and a Medicare Advantage plan 60 days to ask for a reconsideration; after that a denial stands unless the payer accepts good cause for the delay, so a denial left in the queue past its window is written off whatever its chance of winning.

Medicare (fee for service). Fix or appeal: A redetermination request within 120 days of receiving the initial determination, which counts as received 5 days after the notice's date.
Medicare Advantage plans. Fix or appeal: A reconsideration request within 60 days of receiving the plan's written determination, which counts as received 5 days after its date.
Medicaid. Fix or appeal: Set by each state's Medicaid agency.
Commercial insurers. Fix or appeal: Set by the provider's contract and state law.

Sources: 42 CFR 424.44, 42 CFR 405.942, 42 CFR 422.582, 42 CFR 422.520, 42 CFR 447.45

An estimate from published figures, checked on 10 October 2026. Not legal, tax or financial advice.

On this page

What the result means

This represents the cash flow delayed by errors and the direct labour cost required to resubmit them.

Value tied up in denials is money already earned that can't be used until each claim is corrected and paid. For every denial paid in the end it's late, not lost.
Administrative rework cost is the labour to correct, resubmit or appeal each denied claim, at your cost per claim, with every denial worked once.
Lost for good is what never comes back: the denied value not paid in the end, plus the rework. With every denial paid, it's the rework alone.
Each point of denial rate is what one percentage point fewer would hold up and lose each month: the figure to set against what preventing denials costs.
The break-even claim value is where working a denial stops paying. Below it, the rework costs more than the share of the claim you can expect back.

How it works

A claim denial is a payer's refusal to pay a claim as submitted. It can be corrected and resubmitted, appealed, or written off. The denial rate is the share of submitted claims denied the first time; HFMA's Claim Integrity Task Force counts it as initial denials over claims submitted, by number and by charges.

The tool calculates the volume of denied claims using your stated denial rate. It multiplies that volume by your average claim value to find delayed revenue, and by your stated rework cost to find the operational overhead. It assumes all denied claims require manual rework.

Denied claims = monthly claim volume × denial rate ÷ 100.
Value tied up in denials = denied claims × average claim value.
Administrative rework cost = denied claims × rework cost per claim.
Total monthly financial impact = value tied up + rework cost.
Written off = value tied up × (1 − share paid in the end ÷ 100).
Lost for good = written off + rework cost.
Break-even claim value = rework cost per claim ÷ (share paid in the end ÷ 100).
Denials to work a day = denied claims × 12 ÷ 260 working days.

Assumptions

Every denied claim is worked once, as the headline formula assumes. A denial worked twice, say corrected and then appealed, costs its rework twice.
One denial rate and one average value cover every claim. Denials cluster by payer and service, and higher-value claims can be denied more often (Premier's hospitals reported an average denial on charges of $14,000 and up), so a rate counted by value gives a truer figure than one counted by number.
The share paid in the end applies to the denied value, whatever happens to each claim: some are paid in full on correction, some partly, some never.
A year has 260 working days, for the daily figure.
Amounts are whole currency units, truncated, never rounded up.
Outside the US, the example claim value and rework cost are the US examples converted at the ECB reference rates of 9 October 2026. They are starting points to replace with your own, not local market rates.

Example

Example: a clinic, every denial paid in the end

10,000 claims a month at an average of $250, 10% of them denied, $25 to rework each, and every denial paid in the end:

Denied claims: 10,000 × 10% = 1,000.
Value tied up: 1,000 × $250 = $250,000.
Rework: 1,000 × $25 = $25,000.
Total monthly financial impact: $250,000 + $25,000 = $275,000.

If a clinic processes 10,000 claims a month at $250 each, a 10% denial rate halts $250,000 in cash flow. At $25 per rework, the operational cost alone is $25,000 a month.

Example: when only some denials are paid

5,000 claims a month at $500, 15% denied, $30 to rework each, and 54.3% of denied value paid in the end, the share Premier's hospitals reported for private payers' denials:

Denied claims: 5,000 × 15% = 750.
Value tied up: 750 × $500 = $375,000.
Rework: 750 × $30 = $22,500.
Total monthly financial impact: $375,000 + $22,500 = $397,500.
Written off: $375,000 × 45.7% = $171,375.
Lost for good: $171,375 + $22,500 = $193,875.

The headline is $397,500 a month, but $171,375 of it is never paid. With the rework, these denials cost $193,875 a month for good, $2,326,500 a year.

When this is wrong

The headline assumes all denials are reworked and eventually paid. It does not account for hard denials (write-offs), which represent permanently lost revenue, making actual losses much higher; enter the share of denied value you're paid in the end, and Lost for good counts them.

Denials that are never worked. More than half of denied claims are never reworked, an AAFP article reported in 2015, citing MGMA. An unworked denial costs no rework but is written off in full, so lower the share paid rather than the rework cost.
Denials worked more than once. A claim corrected, denied again and then appealed costs its rework two or three times; raise the rework cost to the average across all attempts.
Line denials. When one line of a claim is denied and the rest is paid, only that line's value is held up. Enter the average denied amount as the claim value, not the whole claim's.
The cost of waiting. The tied-up value is counted once, not the interest or the credit line that carries it while denials age.
Deadlines. A denial not worked before its appeal window closes is lost whatever its chance of winning; each country's windows are under Rules by country.
Patient balances. A denial moved to the patient's responsibility isn't written off yet, but it may become bad debt.

To size the team that works denials and codes the claims, use the medical coding FTE calculator.

What we couldn't confirm

Official source unavailable. India's insurer deadline for settling a claim and the interest owed after it: the regulator's site, IRDAI, is down.
Not found in official sources. The text of Dubai's November 2025 claims management directive; its terms come from a law firm's summary.

Rules by country

For each country in the tool: how long providers have to file a claim and to fix or appeal a denial, whether the payer must pay by a deadline, the rule that most changes what a denial costs, and the denial rates published there.

United States

Medicare (fee for service) (42 CFR 424.44; 42 CFR 405.942)

File: Within 1 calendar year of the date of service.
Fix or appeal: A redetermination request within 120 days of receiving the initial determination, which counts as received 5 days after the notice's date.

Medicare Advantage plans (42 CFR 422.582; 42 CFR 422.520)

File: Set by the provider's contract with the plan.
Fix or appeal: A reconsideration request within 60 days of receiving the plan's written determination, which counts as received 5 days after its date.
Payer pays: Clean claims from providers without a contract: 95% within 30 days, with interest after that, and their other claims paid or denied within 60 days. Contracted providers are paid on the contract's terms.

Medicaid (42 CFR 447.45)

File: Within 12 months of the date of service.
Fix or appeal: Set by each state's Medicaid agency.
Payer pays: 90% of practitioners' clean claims within 30 days of receipt, 99% within 90 days.

Commercial insurers

File: Set by the provider's contract and state law.
Fix or appeal: Set by the provider's contract and state law.

The rule to know: The clock starts at the denial notice. Medicare allows 120 days to ask for a redetermination and a Medicare Advantage plan 60 days to ask for a reconsideration; after that a denial stands unless the payer accepts good cause for the delay, so a denial left in the queue past its window is written off whatever its chance of winning. (42 CFR 405.942; 42 CFR 422.582)

Worth knowing: Few denials are ever challenged. Insurers on HealthCare.gov denied 19% of in-network claims in 2024 and fewer than 1% of denied claims were appealed. Of the reasons insurers reported, 25% were administrative, 13% an excluded service, 9% a missing prior authorisation or referral, 5% medical necessity and 36% 'other'. In Medicare Advantage, only 1% of denials were appealed in 2014–16, and the plans overturned 75% of those themselves. (KFF; OIG, MA appeals 2018)

Published rates: 8% for single-specialty practices' first submissions (MGMA, 2023 data) (MGMA Stat, 2024); about 15% for hospitals' claims to private payers (Premier survey of 516 hospitals, 2022 claims) (Premier); 19% for HealthCare.gov plans' in-network claims (KFF from CMS data, 2024) (KFF).

Canada

Ontario (OHIP) (OHIP bulletin 231001; OHIP claims submission; Health Insurance Act (Ontario))

File: Within 3 months of the date of service, for services from 1 April 2023 (6 months before).
Fix or appeal: A claim sent in time that comes back on the claims error report can be corrected and resubmitted after the 3 months. Underpayments are queried within 7 months of the remittance advice, and a General Manager's decision can go to the Appeal Board within 30 days.
Payer pays: Monthly: claims received by the 18th are usually processed for approval the following month.

British Columbia (MSP) (Medicare Protection Act (BC); B.C. Reg. 426/97)

File: Within 90 days of the date of service; the Medical Services Commission may pay a later claim at its discretion.
Fix or appeal: A request for reassessment within 90 days.

The rule to know: The windows are short, and an office's own mistakes don't stretch them. Ontario rejects claims sent more than 3 months after the service as stale-dated (error code VJ7), and administrative or operational errors in a physician's office are not extenuating circumstances; British Columbia allows 90 days to submit a claim and 90 days to ask for a reassessment. (OHIP bulletin 231001; OHIP billing brief; B.C. Reg. 426/97)

Worth knowing: Provincial plans also recover money after paying it. Ontario's ministry found anomalies that may include inappropriate billing in 3% to 5% of the fee-for-service claims it examined in 2024; interest runs on an ordered repayment from the date of the decision, and British Columbia adds a 5% surcharge to an amount a practitioner is ordered to repay. (Health Insurance Act (Ontario); Auditor General of Ontario; Medicare Protection Act (BC); B.C. Reg. 426/97)

United Kingdom

Private medical insurers (FCA DISP 1.6)

File: Set by the insurer's terms with the hospital or consultant.
Fix or appeal: A complaint to the insurer, which must send its final response, or explain why it can't yet, within 8 weeks; the complaint can then go to the Financial Ombudsman Service.

The rule to know: For privately funded care, the FCA requires insurers to handle claims promptly and fairly, help a policyholder make a claim, not reject one unreasonably, and settle promptly once terms are agreed. Those duties are owed to the policyholder, so a declined claim is usually disputed through the patient's own complaint. (FCA ICOBS 8.1)

Worth knowing: The Financial Ombudsman Service took on 1,938 new complaints about private medical or dental insurance in 2025/26 and upheld 22% of those it resolved, against 30% across all products. (Financial Ombudsman Service)

Germany

Statutory health insurance (GKV), hospital bills (§ 275c SGB V; § 109 SGB V; § 17c KHG; Bundesgesetzblatt; GKV-Spitzenverband and Deutsche Krankenhausgesellschaft)

File: Payment claims expire two years after the end of the calendar year they arose in.
Fix or appeal: Once a bill is sent the hospital can't correct it, except to apply an audit finding or a court ruling. In an audit the hospital has 8 weeks to send its records and 6 weeks to contest the insurer's decision, and makes any correction within 4 weeks.
Payer pays: Within 5 days of receiving the bill. An audit must start within 4 months, and one that finds nothing to reduce earns the hospital a €300 flat fee, €500 from 2027.

The rule to know: A reduced bill costs more than the difference. Since 12 December 2024, a hospital whose share of audited bills that pass is under 60% pays a €400 surcharge on each bill reduced after audit, and the same share sets how many of its bills insurers may audit: up to 5%, 10% or 15%. From 1 January 2027 the surcharge is €500 below an 80% pass share, and the quota rises to as much as 40%, with no limit below 50%. (§ 275c SGB V; Bundesgesetzblatt)

Worth knowing: About every second audited hospital bill is cut. The Medizinischer Dienst audited about 1.18 million hospital bills in 2025 and found 53.7% of them incorrect, and the federal government puts the average audit rate at under 10% of bills, down from about 17%. (Medizinischer Dienst Bund; Deutscher Bundestag)

India

Health insurers and their TPAs (Press Information Bureau, Ministry of Finance)

File: Set by the policy and the insurer's agreement with the hospital.
Fix or appeal: Set by the policy. Complaints are tracked on IRDAI's Bima Bharosa portal, which recorded 1,37,361 general and health insurance grievances in 2024-25.
Payer pays: Cashless claims: pre-authorisation within 1 hour and final authorisation within 3 hours, under IRDAI's timelines.

Ayushman Bharat PM-JAY (National Health Authority (hosted by the State Health Agency, Uttarakhand); Comptroller and Auditor General of India)

File: Within 7 days of discharge to be paid in full: a later claim loses 0.1% a day, and none is admitted after 45 days (60 for public hospitals), under the rules the CAG audited in 2023.
Fix or appeal: To the District Grievance Committee within 30 days of the rejection, then to the State committee within 30 days.
Payer pays: Within 15 days of receiving the complete claim (30 days for claims from outside the state), or a penalty of 1% of the claim for each week of delay, paid to the hospital.

The rule to know: Under PM-JAY lateness costs both sides. A claim filed more than 7 days after discharge loses 0.1% a day and isn't admitted after 45 days (60 for public hospitals), under the rules the CAG audited in 2023; the scheme's guidelines have it settle a complete claim within 15 days (30 for out-of-state claims) or pay the hospital 1% of the claim a week, and a rejection can be appealed to the District Grievance Committee within 30 days. (National Health Authority (hosted by the State Health Agency, Uttarakhand); Comptroller and Auditor General of India)

Worth knowing: Most of what insurers don't pay is cut from a claim rather than refused: the Ministry of Finance lists the sum insured, co-payment, sub-limits, deductibles, room-rent caps, proportionate charges and non-medical expenses as the usual reasons. Health insurers paid 87.5% of claims by number in 2024-25. (Press Information Bureau, Ministry of Finance)

Singapore

MediSave and MediShield Life (MOH circular 30/2015; CPF Board)

File: Within two weeks of the visit or discharge, under MOH's requirements for medical institutions.
Fix or appeal: Not set out in the MOH and CPF guidance checked.

Integrated Shield Plan insurers (CPF Board; MOH, Integrated Shield Plans)

File: The insurer assesses the claim first, so it can take longer than two weeks.
Fix or appeal: Set by each insurer.
Payer pays: Pre-authorisation, where offered: AIA, Great Eastern, HSBC Life, Prudential and Raffles each target 3 working days once documents are in.

The rule to know: A claim can be cleared before admission. AIA, Great Eastern, HSBC Life, Prudential and Raffles offer pre-authorisation on Integrated Shield Plans and each target 3 working days to decide once the documents are in; Income doesn't offer it, and Singlife stopped in September 2023. (MOH, Integrated Shield Plans)

Worth knowing: When Integrated Shield Plan insurers didn't pay a claim, the reason was most often a claim at or under the deductible (69%), then a general exclusion (20%) and a pre-existing illness (8%), MOH reports. Those figures leave out claims rejected for errors that need resubmitting. (MOH, Integrated Shield Plans)

Philippines

PhilHealth (PhilHealth Circular 2025-0019; PhilHealth claim form reminders; PhilHealth Advisory 2025-0011)

File: Within 60 days of the patient's discharge; PhilHealth may extend this for reasonable cause.
Fix or appeal: A claim returned for correction must be refiled within 60 days of receiving the notice, or it's denied. A denied claim can be protested to the Regional Office, then appealed.
Payer pays: Within 60 days; good claims took 24 days on average in 2024.

The rule to know: Filing late is the costliest mistake: 30% of the claims PhilHealth denied from 2018 to 2024 were filed late, and a returned claim not refiled within 60 days of its notice is denied. A one-off window to refile late claims from those years closed on 31 March 2026. (PhilHealth Circular 2025-0019; PhilHealth claim form reminders; PhilHealth news, 2025)

Worth knowing: About 5.3% of the claims PhilHealth received in 2024, worth around ₱10 billion, were denied or returned to hospitals for deficiencies or breaches of its rules. (PhilHealth Advisory 2025-0011)

Published rates: about 5.3% for claims PhilHealth denied or returned to hospitals (PhilHealth, 2024) (PhilHealth Advisory 2025-0011).

Malaysia

Medical and health insurance and takaful (BNM claims settlement practices)

File: Set by the policy.
Fix or appeal: A repudiated claim gets the reasons in writing, and the dispute can go to the Ombudsman for Financial Services within 6 months of the insurer's final decision.
Payer pays: General insurers and takaful operators reimburse medical claims within 7 working days of receiving the original bills; life insurers' medical policies fall outside that rule.

The rule to know: A rejection has to be explained. An insurer must give a clear explanation of a total or partial rejection, naming the policy terms or exclusions it rests on, and to deny a claim for a pre-existing condition it must prove the policy owner knew of the condition or was reasonably aware of it. (BNM fair treatment; BNM MHIT policy)

Worth knowing: Bank Negara Malaysia's claims settlement deadlines bind general insurers and takaful operators; medical cover sold by life insurers and family takaful follows its own policy terms and the fair-treatment rules. (BNM claims settlement practices; BNM fair treatment)

United Arab Emirates

Dubai (DHA) (DHA notice 03/2019; Al Tamimi & Company, on GCC BDI)

File: Set by the claims management directive in force since 16 November 2025, whose full text wasn't published to check; the 2019 standard it replaced required claims by the 15th of the month after the service.
Fix or appeal: Up to two resubmissions of a disputed claim; the 2019 standard set the first within 21 days of the remittance advice giving the denial reason.
Payer pays: Within 45 days of a claim and 30 days of a resubmission. A late claim costs 0.03% of the net amount claimed for each day.

Abu Dhabi (DOH) (DOH Circular 26/2022; DOH Circular 133/2020; Shafafiya rules)

File: Within 30 days of the end of the month of service. A late claim loses 0.03% a day, and the insurer may reject one sent more than 90 days after the deadline.
Fix or appeal: Disputed and rejected claims are resubmitted within 45 days of the payment or the remittance advice with the denial code.
Payer pays: Within 30 days for Basic products and 45 days for Thiqa and Enhanced products, with a delay fee after that.

The rule to know: Every rejection is coded and the windows to fight it are short. Payers must give a published denial code on every full or partial rejection; a disputed Dubai claim gets at most two resubmissions, and in Abu Dhabi a rejected claim must be resubmitted within 45 days. Late claims cost 0.03% of the claim a day in both. (DHA notice 02/2019; Al Tamimi & Company, on GCC BDI; DOH Circular 26/2022; Claims adjudication standard)

Worth knowing: Abu Dhabi's Department of Health scores providers and payers on their rejection and resubmission rates as quality indicators, and because each remittance advice carries a denial code, rejections can be counted by cause straight from the remittance data. (Claims adjudication standard; DOH adjudication rules 2025)

Australia

Medicare, bulk-billed claims (Services Australia, late lodgement; Services Australia, bulk bill claims; Department of Health, Disability and Ageing (MBS Online))

File: Within 1 year of the date of service, for services from 5 September 2025 (2 years before).
Fix or appeal: A rejected claim comes back with a reason code. A late lodgement can be applied for, but isn't approved for administrative errors.

Private health insurers (Bupa; Defence Health)

File: Set by each fund: Bupa and Defence Health take claims up to 2 years from the date of service.
Fix or appeal: Set by each fund; Bupa returns incomplete claims to be resubmitted.
Payer pays: Bupa aims to pay valid claims within 30 business days of receiving them, once the Medicare rebate is paid.

The rule to know: The Medicare clock halved in 2025: bulk-billed services from 5 September 2025 must be claimed within 1 year instead of 2, and Services Australia won't approve a late lodgement caused by an administrative error, so a rejection fixed after the year is a write-off. (Services Australia, late lodgement; Department of Health, Disability and Ageing (MBS Online))

Worth knowing: Each rejected Medicare claim comes back with a three-digit reason code (162 is a duplicate service), so rejections can be counted by cause. (Services Australia, bulk bill claims)

Anywhere else

The rule to know: Every payer runs a clock: a time to file the claim, a shorter one to fix or appeal a denial, and sometimes a deadline to pay. A denial worked after its window closes is written off whatever its chance of winning, so check each payer's rules and contract.

Worth knowing: Where payers send a reason code with each denial, counting denials by code and by payer shows which causes to fix first.

Sources

Every source this page cites (56)

Each one was opened and checked on the date beside it.

MGMA6 keys to addressing denials in your medical practice18 March 2021
MGMAStrategic improvements in your RCM to reduce your practice's claim denials (MGMA Stat)5 March 2024
PremierTrend alert: private payers retain profits by refusing or delaying legitimate medical claims21 March 2024
KFFClaims denials and appeals in ACA Marketplace plans in 202424 March 2026
HFMAStandardizing denial metrics for revenue cycle benchmarking and process improvement2026
AAFP, Family Practice ManagementThe cure for claims denials2015
European Central BankEuro foreign exchange reference rates9 October 2026
eCFR42 CFR 424.44, time limits for filing claims8 October 2026
eCFR42 CFR 405.942, time frame for filing a request for a redetermination8 October 2026
eCFR42 CFR 422.582, request for a standard reconsideration8 October 2026
eCFR42 CFR 422.520, prompt payment by Medicare Advantage plans8 October 2026
eCFR42 CFR 447.45, timely claims payment (Medicaid)8 October 2026
US Department of Health and Human Services, Office of Inspector GeneralMedicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials (OEI-09-16-00410)2018
Ontario Ministry of HealthBulletin 231001: update, three-month submission timeframe for in-province claims4 October 2023
Ontario Ministry of HealthClaims submission (resources for physicians)22 April 2026
Government of Ontario, e-LawsHealth Insurance Act, R.S.O. 1990, c. H.625 September 2023
King's Printer for British ColumbiaMedicare Protection Act6 October 2026
King's Printer for British ColumbiaMedical and Health Care Services Regulation, B.C. Reg. 426/976 October 2026
Ontario Ministry of Health and Ontario Medical AssociationRules regarding claim submission periods and stale-dated claims17 January 2025
Auditor General of OntarioOversight of physician billing (Annual Report 2025)2025
Financial Conduct AuthorityDISP 1.6 Complaints time limit rules1 June 2026
Financial Conduct AuthorityICOBS 8.1 Insurers: general1 August 2017
Financial Ombudsman ServiceAnnual complaints data and insight 2025/2621 May 2026
Bundesamt für Justiz§ 109 SGB V, Abschluss von Versorgungsverträgen mit Krankenhäusern2026
Bundesamt für Justiz§ 17c KHG, Prüfung der Abrechnung von Pflegesätzen2026
GKV-Spitzenverband and Deutsche KrankenhausgesellschaftUmsetzungshinweise zur Prüfverfahrensvereinbarung (PrüfvV) vom 22.06.202129 November 2021
Bundesamt für Justiz§ 275c SGB V, Durchführung und Umfang von Prüfungen bei Krankenhausbehandlung12 December 2024
BundesgesetzblattGKV-Beitragssatzstabilisierungsgesetz (Bundesgesetzblatt 2026, Nr. 228)29 July 2026
Medizinischer Dienst BundBericht über die Tätigkeit und Personalausstattung der Medizinischen Dienste 2024–20251 June 2026
Deutscher BundestagGesetzentwurf der Bundesregierung, Drucksache 21/613026 May 2026
Press Information Bureau, Ministry of FinanceHealth insurance sector records strong growth momentum in 2024-2526 March 2026
Comptroller and Auditor General of IndiaPerformance audit of Ayushman Bharat PM-JAY (Report No. 11 of 2023), chapter V: claims management8 August 2023
National Health Authority (hosted by the State Health Agency, Uttarakhand)PMRSSM guidelines on claim settlement2018
Ministry of Health, SingaporeAudit requirements for MediSave/MediShield Life claims submissions (FCM No. 30/2015)22 December 2015
CPF BoardWhy are my MediSave and MediShield Life claims not processed after my visit or hospital discharge?25 February 2025
Ministry of Health, SingaporeComparison of Integrated Shield Plans5 August 2026
PhilHealthCircular 2025-0019: flexibility in claims submission deadline for claims filed from 1 January 2018 to 31 December 2024 (revision 1)23 October 2025
PhilHealthImportant reminders for the implementation of PhilHealth claim forms 1, 2 and 32013
PhilHealthAdvisory 2025-0011: good claims ensure faster payment7 March 2025
PhilHealthPhilHealth to process 1.1M denied claims due to late filing of hospitals2025
Bank Negara MalaysiaClaims settlement practices (BNM/RH/PD 029-69)1 July 2024
Bank Negara MalaysiaFair treatment of financial consumers (BNM/RH/PD 028-103)27 March 2024
Bank Negara MalaysiaMedical and health insurance/takaful business (BNM/RH/PD 029-66)29 February 2024
Al Tamimi & Company, on GCC BDIDubai issues comprehensive overhaul of health insurance claims management framework2025
Dubai Health Authority (DHIC)eClaimLink standards notice 03/2019: claim cycle standardisation31 July 2019
Department of Health, Abu DhabiCircular 26 of 2022: revision and update of the Standard Provider Contract18 January 2022
Department of Health, Abu DhabiCircular 133 of 2020: Standard Provider Contract9 December 2020
Department of Health, Abu DhabiShafafiya business rules8 March 2018
Dubai Health Authority (DHIC)eClaimLink standards notice 02/20191 August 2019
Health Authority Abu Dhabi (now the Department of Health)Health insurance claims adjudication standard (HSF/CA/1.0)2010
Department of Health, Abu DhabiDOH claims and adjudication rules V2025.11 November 2025
Services AustraliaBulk bill late lodgement claims in Medicare (011-43030020)2026
Services AustraliaBulk bill claims in Medicare (011-43030000)2026
Department of Health, Disability and Ageing (MBS Online)Reduced timeframe to submit claims for bulk billed services8 September 2025
BupaBupa Medical Gap Scheme terms and conditions1 February 2025
Defence HealthGeneral claiming conditions2026

Frequently asked questions

What is a standard rework cost per claim?

The Medical Group Management Association (MGMA) estimates it costs an average of $25 to rework a single denied claim: $25.20, in its figures for medical practices. Hospitals report more; those in Premier's survey spent an average of $43.84 a claim fighting private payers' denials.

What is an acceptable denial rate?

There's no official standard, but the lower the better, and well below your peers: MGMA's 2023 data puts single-specialty practices at 8% of claims denied on first submission, hospitals in Premier's survey reported nearly 15% of claims to private payers denied at first, and HealthCare.gov insurers denied 19% of in-network claims in 2024 (KFF). Change Healthcare found 86% of denials potentially avoidable, so a rate above your peers' usually signals systemic issues in coding or front-end verification.

Why include the claim value in the cost?

While delayed revenue is eventually recovered if the rework succeeds, it restricts cash flow, creates accounts receivable aging, and increases the risk of hard denials due to timely filing limits. Not every rework succeeds: hospitals in Premier's survey were paid in the end on 54.3% of private payers' denials, and the rest was lost, which is why the tool also shows what's lost for good.

Can AI reduce rework costs?

Yes. Predictive models and automated code scrubbing can catch errors before submission, preventing the denial entirely. They catch what the claim itself shows, such as a missing modifier or a code the diagnosis doesn't support; coverage and medical-necessity decisions stay with the payer, and a coder should approve what the software changes.

How long do you have to appeal a denied claim?

It depends on the payer, and the window is short: Medicare allows 120 days from receiving the initial determination to ask for a redetermination, and a Medicare Advantage plan 60 days to ask for a reconsideration, while commercial insurers set theirs in the provider contract. Each country's windows are under Rules by country.

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