Where denials, delays, repeat denials, and low appeal rates are concentrated.
Independent denial oversight for self-funded health plans
Your administrator runs the process. Your committee needs its own record.
We turn claims, prior-authorization, and appeals files into committee-ready evidence about where care is being blocked, what changes after appeal, and what the administrator still has not explained.
What you are buying
A denial oversight review, built around the next decision.
This is independent evidence for plan governance and vendor management. It does not label every denial wrongful, decide individual claims, or promise that a denial will be overturned.
Amounts initially denied, restored after appeal, and tied up in repeated rework.
What records were requested, what the administrator produced, and which gaps remain unresolved.
A concise record of findings, management responses, corrective actions, and renewal questions.
Why this belongs in governance
A formal review process needs evidence from the claims system.
U.S. Department of Labor guidance tells group health plan fiduciaries to establish a formal process for reviewing service providers. That review includes performance, reports, fees, plan records, participant complaints, and questions about a TPA's claims-processing systems.
Our work organizes the denial evidence for that process and records unanswered data requests. It is not a legal opinion, fiduciary certification, or guarantee against litigation.
Read the Department of Labor guide ↗Where the public index stops
A carrier benchmark is context. Your plan's files are the answer.
Public records cover Medicare Advantage, Medicaid managed care, and individual Marketplace plans. They do not reveal what an administrator denied under a particular self-funded employer plan.
The public Denial Index gives us a normalized evidence base and a repeatable way to check sources. A plan audit adds the employer's own de-identified records. We keep those scopes separate so a public carrier rate is never presented as proof of what happened to your workforce.
Three evidence levels
Start where your access to records allows.
The Plan Denial Audit is the full product. The first two engagements establish the public baseline, governance process, and data request needed to reach it. Final scope depends on plan count, data volume, and reporting cadence.
Public Evidence Brief
$12,000–$20,0002 weeksA source-linked review of the administrator's public denial record, disclosure quality, and missing information. Useful before a committee meeting or renewal discussion.
What we need: The administrator and plan arrangement. We use public records.
Oversight Readiness Review
$30,000–$50,0003–4 weeksA review of the committee's current reporting, data rights, escalation process, and TPA questions, ending in a documented oversight agenda and plan-data request.
What we need: One working session plus existing committee and vendor-reporting materials.
Plan Denial Audit
$75,000–$150,0006–8 weeks after data arrivesA plan-specific analysis of denial reasons, appeal and reversal rates, decision times, repeat friction, and automation disclosures, with a committee and renewal scorecard.
What we need: A de-identified claims, prior-authorization, and appeals extract from the administrator.
The plan denial audit
The administrator produces the files. We make them reviewable.
We provide the request letter, field specification, normalization rules, and missing-data log.
- 835 remittance filePaid and denied claim lines, including CARC and RARC denial reason codes.
- Prior-authorization logRequests, decisions, reasons, and the time each decision took.
- Appeals logAppeals, outcomes, reversal reasons, and the time each review took.
- Decision dictionaryThe administrator's labels, clinical or administrative categories, automation disclosures, and system mappings.
What a committee would see
Where the first “no” is costing people time and care.
- Members
- 5,000
- Claim lines
- 72,418
- Plan year
- 2025
9.6% of claim lines were denied on the first pass.
Only 8.4% of denied lines were appealed. Of those appeals, 68.7% were won.
Most denials were administrative. The plan restored $468,000 after people challenged a decision—evidence that preventable friction, not only medical judgment, deserves committee attention.
First-pass denial rate by service
Why lines were denied
- 61% · Administrative
- missing information, coding, filing, eligibility
- 23% · Medical necessity
- the plan said the care did not meet its rules
- 16% · Coverage or benefit
- the service was excluded or outside plan rules
1,284 members touched by a denial411 members faced more than one$1,840,000 initially denied
Synthetic demonstration. The utilization structure comes from Synthea CSV claims and claims-transactions; a documented test layer assigns public CARC/RARC denial codes, appeals, decisions, and timing. The figures are a product fixture, not an industry benchmark.
Private employer briefing
Bring the decision you are preparing for.
Tell us the plan arrangement, administrator, and whether this is for a committee review, renewal, data-access dispute, or member-access concern. We will identify the evidence level that fits.
In “How can we help?”, tell us your organization, plan administrator, and the decision you are preparing for. If you do not know your plan type, say that—we can still start.
Do not include member names, claim numbers, diagnoses, denial notices, or medical records here.
The employer pays. The committee should be able to see what happened.