Denial rate, Statewide Care Program

Formula

Claims a payer denied the first time it decided on them, divided by all claims a payer first decided on in the month. Resubmissions are not counted again.

Claims denied the first time a payer decided on them

33

Claims a payer first decided on in the month

293

Result

11.26%

Filters

• Primary payer only
• The payer’s first decision only
• Self pay left out (no payer decides on it)

Scope

Statewide Care Program

Every version of this definition

athena report

athenaOne Denial Management report, first-pass view, grouped by primary payer

athena’s figure

12.16%

Difference (ours minus athena)

-0.90 points

Tolerance

Up to 0.50 points either way

Evidence

• Open the athena report athena-2025-11-denial-management (sample), sample report, opens in a new tab

Checked

Dec 4, 2025, 9:00 AM EST by Rowan Bexley

Why they differ

athena’s Denial Management report counts a claim again when its corrected resubmission is denied too. Our definition counts only the payer’s first decision on a claim. The report’s claim list shows 3 such resubmission denials for this payer this month, each adding one denial and one decided claim. Take them out and athena’s figure is ours exactly.Current explanation, written by Rowan Bexley, Dec 4, 2025, 10:00 AM EST