To report a denial rate from athenaOne data, count the claims a payer denied on first adjudication and divide by the claims you submitted in the same period, then break that rate down by payer and by denial reason code. Keep a second, separate measure for money you never recover, because a high first-pass denial rate that your team overturns is a very different problem from a quiet stream of write-offs. Use the same written definition every month, or the trend means nothing.
Which denial rates should you track?
"Denial rate" is used loosely, so pick a small set and define each one. The Healthcare Financial Management Association (HFMA) has published standard denial definitions and revenue cycle MAP Keys that are a sound starting point.
| Measure | What it answers | Formula |
|---|---|---|
| Initial denial rate (claims) | How often payers deny us the first time | Claims with a first denial ÷ claims submitted |
| Initial denial rate (dollars) | How much charge value is held up | Charges on claims with a first denial ÷ charges submitted |
| Denial write-offs (final loss) | How much we never collect | Net dollars written off as denials, after recoveries ÷ average monthly net patient service revenue (HFMA AR-6) |
| Clean claim rate | How often claims leave without manual fixes | Claims passing edits with no manual intervention ÷ claims entering your claim tool (HFMA CL-1) |
| First-pass resolution rate | How often a claim is paid in full on the first try | Claims paid with no rework ÷ claims adjudicated (no single standard; write yours down) |
| Overturn rate | Whether appeals are worth the work | Initial denials later paid ÷ initial denials resolved |
A few details from HFMA's definitions matter in practice. Count only the first denial on each claim. Exclude rebills, so a corrected claim is not counted twice. HFMA uses the average claims submitted over the prior three months as the denominator, which smooths the lag between submitting a claim and hearing back.
Also separate rejections from denials. A rejection is a claim sent back before adjudication, usually by a clearinghouse or payer front-end edit, and it never reaches the remittance. A denial is an adjudicated decision that arrives on the remittance advice. Report them side by side, never added together.
What is a good denial rate?
The most useful practice benchmark we found is from the Medical Group Management Association (MGMA): 8% of claims denied on first submission for single-specialty practices in its 2023 DataDive data, the same rate MGMA documented in 2019. In a March 2024 MGMA Stat poll reported in the same article, 60% of medical group leaders said denials were higher than the year before.
You will also see higher figures, such as the Optum 2024 Revenue Cycle Denials Index average of about 12% for 2023. That index is built from about 124 million hospital claim remittances, so it is not a like-for-like comparison for a physician practice.
Our advice: benchmark against your own last twelve months first. An outside number is only useful when its definition (claims or dollars, initial or final, what is excluded) matches yours.
How do you build it from athenaOne data?
You need two kinds of records: the claims you sent and the remittances that came back. In athenaOne, the most direct way to get both at row level is Data View, athenahealth's SQL copy of your data. Confirm the exact tables and columns with your Data View data dictionary, since names vary by package.
- Build a claim spine. One row per original claim, with the payer, rendering provider, department, date of service, submission date and billed charges. Flag corrected claims and rebills so you can exclude them from the denominator.
- Attach adjudication events. From posted remittance and transaction records, take each claim's first adjudication: paid, partly paid or denied, with its group code, reason codes and remark codes.
- Mark the first denial. A claim is an initial denial if its first adjudication denied the claim or a line on it. Keep only the earliest denial per claim.
- Track resolution. Follow each denied claim to its end state: paid on appeal or correction, written off, or still open. That gives you overturn rate, days to resolve and write-offs.
- Load on a settled day. athenahealth notes that the TRANSACTION and CLAIM tables refresh in sequence and can be briefly out of sync. Run your load only after both have refreshed.
Define all of this once in your warehouse, not separately in each dashboard. That is the core of our analytics and BI architecture work, and it is what lets billing, finance and operations quote the same number.
How do you group denial reasons?
Every adjustment on an electronic remittance carries three sets of codes: a group code, a Claim Adjustment Reason Code (CARC) and, often, a Remittance Advice Remark Code (RARC). X12 maintains the CARC list and the RARC list. The group code says who owns the balance: CO (contractual obligation), PR (patient responsibility), OA (other adjustment), PI (payer initiated) or CR (corrections and reversals).
Hundreds of codes are too many for a leadership report. Map them to a dozen work queues. A starting map:
| Group | Example CARCs (X12) | Usually fixed by |
|---|---|---|
| Eligibility and coverage | 27 coverage ended, 22 other payer may be primary, 109 not covered by this payer | Front desk, registration |
| Missing or invalid claim data | 16 missing information, 4 modifier mismatch, 11 diagnosis does not fit procedure | Charge entry, coding |
| Authorization | 197 precertification or authorization absent | Referrals and authorizations |
| Medical necessity and non-covered | 50 not medically necessary, 96 non-covered charge | Clinicians, coding, patient financial counseling |
| Documentation requested | 252 attachment or documentation required | Billing, medical records |
| Bundling | 97 included in another service | Coding |
| Duplicate | 18 exact duplicate | Billing |
| Timely filing | 29 filing limit expired | Billing |
| Not a denial (exclude) | 1, 2, 3 deductible, coinsurance, copay; 45 charge above fee schedule | No action |
The last row matters most. Deductibles, copays and contractual write-downs appear on the same remittance but are not denials. Leave them out, or your denial rate will be wrong from day one.
The Optum index offers a sense of proportion for hospitals: in 2023, registration and eligibility caused about 24% of denials and missing or invalid claim data about 16%. Your own mix will differ, which is the point of grouping your codes.
A weekly review rhythm
A denial report only helps if someone acts on it on a schedule. We suggest a 30-minute weekly review with billing, front desk and clinical leads, using the same one-page report each time:
- Trend. Initial denial rate by week for the last 13 weeks, claims and dollars, plus clean claim rate.
- Where. The same rate by payer and by department, sorted by dollars denied.
- Why. The top five reason groups this week, each with an owner and an open count.
- Money at risk. Open denials by age, flagged against each payer's appeal deadline.
- Actions. Last week's fixes, whether the reason they targeted went down, and this week's one or two changes.
Keep a monthly view of write-offs and overturn rate for leadership. Weekly numbers are noisy for small payers, so read them as a trend, not a verdict. Denial rate belongs on your practice KPI scorecard, next to days in accounts receivable.
Where to start
Write your denial definitions on one page this week: what counts as a claim, a first denial, a rebill and a write-off. Then pull 90 days of remittances, map their CARCs to the groups above, and see which three groups carry most of the dollars. If you want help building the report on your athenaOne data so it runs itself every week, book a free strategic assessment through our contact page.