Charge Denial Rate Calculator

Total Dollars Reviewed: Determine what the Medicare reimbursement amount would have been for each claim if it were paid as billed.

Total Dollars Denied: is based on the ‘reviewed charges.’ For example, if a partial payment were allowed on the claim, the denied charges would equate to the difference between the amount that would have been paid if the claim had paid as billed and the amount that was actually paid.

To obtain the information needed to calculate the CDR, you will need to have your Remittance Advices (RAs), and access to the Direct Data Entry (DDE) system.

• Full payment made: The payment amount will be on the RA when the processing of the claim is finalized.
• Partial payment made: The RA will reflect the amount paid.
• • The amount denied or any down coded line items can be viewed in the DDE system using the claims inquiry menu option.
  • • The total amount that would have been paid had the claim been paid as billed minus the actual payment amount equals the denied charges.
    • Claim page 4 will display the notes from the review that explain the reason for the denied or down coded charges and any additional errors that may have been identified during the review.
• Denied Payment: The RA shows the reason code that coincides with the denial reason code, which may be viewed in the DDE system using the claims inquiry menu option.
• • Denied charges are calculated based on the difference between the amount that would have been paid had the claim been paid as billed and the amount that was actually paid.
  • Claim page 4 will display the notes from the review that explain the reason for denial and any additional errors that may have been identified during the review.

Note: For claims reviewed that are partially or fully denied, a Denial Education Letter is mailed to the provider. The letter contains an explanation of the reason for any denied charges, additional errors that may have been identified during the review, information on how to appeal the denial, and how to request education.

For more information regarding the medical review process, please visit our Targeted Probe and Educate webpage.