Denial Management for Primary Care Physicians

Eligibility checks and prior authorization tracking prevent claim denials in primary care.

Altair Health 4 October 2026

Denial management for primary care physicians is the work of preventing, catching and appealing denials on office visits, annual wellness visits, problem visits billed with them and chronic care management. For family medicine and internal medicine practices, the risk is volume: a failure built into intake or a template repeats on every claim that passes through it.

The 2026 plan year added a new failure at intake. Medicare Advantage plan exits forced 2.9 million enrollees, one in ten in HMO and PPO plans, to leave their plans for 2026, according to a JAMA research letter. A patient who checks in with last year's card produces a claim that last year's plan will not pay.

The other failures sit in a few places. Medicare denies a wellness visit billed inside the 12-month window after the last one. A problem visit on the same day as an annual wellness visit can pay only as its own service, with modifier 25. Care management claims need consent on file and the minutes to support the code. And some office visits pay at a lower level with no denial on the remittance.

Primary care denial rates and what the national data measures

Kodiak Solutions put the 2024 initial denial rate at 11.81% of claims for hospitals and physician practices combined, up 2.4% from 2023. Its data came from more than 2,100 hospitals and 300,000 physicians on its platform. Kodiak's Matt Szaflarski said payers appear to use initial denials to slow payments, though they pay about 90% of claims in the end.

The first half of 2026 looked different. Across all payers combined, Kodiak's analysis of more than 2,300 hospitals and 375,000 physicians found initial and final denial rates down from the first half of 2025. Payers took more back instead. Takebacks rose from 1.38% to 1.57% of accounts receivable. Medicare Advantage insurers had higher initial and final denial rates than traditional Medicare, and more than double its percentage of takebacks. On commercial claims, the initial denial rate fell but the final denial rate rose. Neither Kodiak release gives a figure for primary care.

Eligibility denials after the 2026 Medicare Advantage plan exits

Forced disenrollment from Medicare Advantage plans averaged 1.0% a year from 2018 through 2024, rose to 6.9% in 2025 and reached 10.0% for 2026, according to the JAMA research letter. Enrollees forced out had to find new plans or switch to traditional Medicare. They were more likely to have been in PPOs: 49% of them, against 31% of enrollees who could keep their plan.

A move from a PPO to an HMO changes what the claim needs. In most Medicare HMOs the patient has to choose a primary care doctor, and in most cases needs a referral to see a specialist, according to Medicare.gov. Medicare PPOs require neither. Outside an HMO's network, apart from emergency care, urgent care and out-of-area dialysis, the patient may have to pay the full cost. Patients in the middle of treatment get some protection. A new Medicare Advantage plan has to give them at least 90 days before it can require a new prior authorization for ongoing treatment. Our post on denial management for urologists covers how that transition works.

Eligibility failures come back under a few reason codes. A claim sent to the plan the patient left can return as CO-27, expenses incurred after coverage terminated. CO-109 means the claim went to a payer or contractor that does not cover it, and it has to go to the correct one. CO-22 means another payer may be responsible under coordination of benefits. The X12 code list has the official wording, and our pages on CO-27 and CO-22 cover the fixes.

The fix is an eligibility check before every visit, including for patients the practice has seen for years. Confirm more than active coverage. Check the plan type, the network and the primary care doctor on file. Then check whether any planned service needs prior authorization under the current plan. A plan change should surface at scheduling, not on the remittance. Our post on the top 10 claim denial reasons covers intake errors and why one eligibility check is not enough.

Prior authorization denials in primary care

Insurers denied 12% of standard prior authorization requests in Medicare Advantage in 2025, according to KFF's analysis of the first public reports required under CMS-0057-F. The rates were 14% in Medicaid managed care and 18% on the ACA Marketplace. KFF covered 14 insurers, each with at least 2.5% of its market, and its Marketplace figures cover the 28 HealthCare.gov states. The reports combine all medical services except prescription drugs, so they do not show which services insurers denied.

These decisions come before care. They are not claim denials. Appeals are rare, KFF notes, but a considerable share succeed. Insurers overturned 67% of appealed standard request denials in Medicare Advantage, 47% in Medicaid managed care and 43% on the Marketplace. KFF says high overturn rates could mean the insurer should have approved the first request, or that the request lacked the documentation to justify the service.

Either way, send the request complete, with the documentation the payer's policy asks for. A denied request is not lost revenue yet, because the service has not happened. An approval does not settle the claim either. Our post on why prior authorization approval does not guarantee payment covers what can still deny it and the spread between insurers.

CMS-0057-F, CMS's Interoperability and Prior Authorization final rule, set prior authorization deadlines starting in 2026 for Medicare Advantage, Medicaid and CHIP. Expedited requests get a decision within 72 hours and standard ones within seven calendar days. Medicare Advantage and Medicaid managed care plans can extend either deadline by up to 14 calendar days in limited cases, under 42 CFR 422.568, 422.572 and 438.210. Those payers, plus ACA Marketplace insurers on HealthCare.gov, must also give a specific reason for each denied request. That gives a practice something concrete to fix or appeal. None of it applies to drugs. Our post on denial management for cardiologists covers which payers it leaves out.

The authorization work itself needs one owner from request to claim. Track each approval against its expiration date and the service it covers, and put the approval number on the claim before it goes out. Keep a payer-by-payer list of the services that need authorization. If a service happens without a required approval, the fallback is a retro authorization request, on the payer's terms and inside its window. Our post on retro authorization covers how payers review those requests.

Annual wellness visit denials: G0438, G0439 and the 12-month window

Medicare pays for one annual wellness visit, or AWV, billed as G0438 or G0439, in a 12-month period, according to the CMS wellness visit page. It pays the first, G0438, once per lifetime. Every later AWV is a G0439, even when a new clinician performs it, under chapter 12 of the claims processing manual. Medicare also denies an AWV within 12 months of the initial preventive physical exam, the IPPE, billed as G0402. The same goes for an AWV in the patient's first 12 months of Part B, under section 140.6 of chapter 18.

The 12 months run in whole months. CMS instructs its claims system to count 11 full months, starting with the month after the month of the last AWV, in Transmittal 2575. So an AWV on March 20, 2026, makes the next one payable from March 1, 2027. Schedule the next one by month, and check it against the patient's Medicare history, not only your chart. A Medicare eligibility check can return the patient's next eligible date for G0438 and G0439. Request service type BZ, a well office visit, and the response includes the date if the data is available, per the CMS eligibility companion guide.

On a Medicare remittance, the claim adjustment reason code, or CARC, tells you which limit the claim hit. A second G0438 comes back with CARC 149, lifetime benefit maximum, and remark code N117. A G0439 too soon after the last AWV comes back with CARC 119, benefit maximum for this time period or occurrence, and remark code N130. An AWV too soon after the IPPE gets the same two codes. An AWV in the first 12 months of Part B comes back with CARC 26, expenses incurred prior to coverage, and remark code N130. All of them carry group code PR, patient responsibility, under section 140.7 of the same chapter.

Modifier 25 for same-day annual wellness and problem visits

Medicare can pay for a problem-oriented evaluation and management visit, or E/M visit, on the same day as an AWV if it is significant, separately identifiable and medically necessary. Report it as 99202 to 99205 or 99211 to 99215 with modifier 25, per the CMS wellness visit page. Document the problem with its own assessment and plan, so the note shows a separate service.

A routine physical is a different case. Medicare does not cover the preventive medicine codes 99381 to 99397, and the manual bars using them for an AWV. If a covered problem visit happens during a noncovered physical, Medicare pays the problem visit and treats it as replacing part of the physical. The practice may charge the patient the difference between its charge for the physical and its charge for the visit.

G2211, the office visit complexity add-on, has its own modifier 25 policy. Medicare denies G2211 on an office visit billed with modifier 25, per the CMS E/M guide. Since January 1, 2025, there is one exception: the same practitioner also provides an AWV, a vaccine administration or any Medicare Part B preventive service that day. Home and residence visits joined that exception on January 1, 2026, according to the CMS G2211 FAQ.

Chronic care management denials: eligibility, consent and minutes

Chronic care management, or CCM, pays for care coordination between visits. The patient needs two or more chronic conditions expected to last at least 12 months, or until death. The conditions have to put the patient at significant risk of death, acute exacerbation or decompensation, or functional decline, according to the CMS booklet on CCM.

Medicare requires an initiating visit before CCM starts for new patients and for patients the billing practitioner has not seen within the previous year. That visit can be an AWV, an IPPE or what CMS calls a "comprehensive face-to-face" E/M visit, and you have to discuss CCM during it. Consent comes next. Get it, written or verbal, before the first CCM claim. Tell the patient that CCM is available, that they may owe cost sharing and that they can stop at any time, effective at the end of the month. Also tell them that only one practitioner can bill CCM in a calendar month. Document that you told them, and whether they accepted. The patient consents once, unless they switch to a different CCM practitioner.

Time, and who spends it, decides the code. 99490 covers the first 20 minutes of clinical staff time in a calendar month, and 99439 each additional 20. 99491 covers the first 30 minutes of physician or other qualified professional time, and 99437 each additional 30. Complex CCM also requires moderate or high complexity medical decision making. It uses 99487 for the first 60 minutes of clinical staff time, and 99489 for each additional 30. You cannot bill complex and non-complex CCM for the same patient in the same calendar month. Minutes counted toward any other billed code cannot count toward CCM, per the booklet.

Each requirement is a denial point. Before each monthly claim, confirm the consent date, the initiating visit, the minutes and who logged them. Ask new CCM patients whether another practice already bills it for them.

E/M downcoding: a primary care loss outside the denial queue

Downcoding is a payment at a lower level of service than the one billed, and it can leave no denial on the remittance. A downcode is easy to miss unless someone checks every payment, the Illinois State Medical Society says in its 2026 downcoding report. Some payers pay the lower rate but leave the billed code unchanged, per an AMA guide. Check each E/M payment against the rate for the level you billed, not only the code on the remittance.

Since January 1, 2023, CMS says to pick the level for most E/M visit families by medical decision making or by the time spent with the patient. History and exam still have to meet the code descriptors, but they do not affect the level. If you pick the level by time, document a start and stop time or the total time, per the CMS guide.

A clean claim proves only that the claim passed the payer's edits, not that the note supports the level billed. A note that reads like a straightforward visit, attached to a high-level code, invites a downcode. The note has to show the decisions or the time behind the level, in terms a reviewer can match to the code.

Turning primary care denials into a process fix

Every denial above traces back to a step before the claim: the eligibility check, the authorization, the AWV history, the consent record, the note. Resubmitting fixes one claim. Fixing the step fixes every claim behind it. Categorize each denial by reason code, by payer and by service, such as office visit, AWV or CCM. Sorting by payer exposes a plan that changed its policy. Sorting by service shows which step in the office keeps failing.

Work every denial inside the payer's filing and appeal windows. In traditional Medicare, the filing limit is one calendar year from the date of service, under 42 CFR 424.44. The first level of appeal, a redetermination, is due within 120 days of receiving the denial, under 42 CFR 405.942. Other payers set their own windows, and our post on the top 10 denial reasons covers how their filing limits differ. Our denial code reference covers what each reason code requires, and the primary care billing guide collects our reference pages for the specialty.

Payer knowledge tends to sit with one biller and leave with them, as our post on billing staff turnover covers.

Altair runs the whole revenue cycle for primary care practices, from eligibility checks before each visit through prior authorization, claim scrubbing, denials, appeals and payment posting. It keeps what it learns about each payer in the system rather than in a person. Altair's AI and in-house billers work every denial. The practice owner sees every claim and every dollar as it moves, not in a monthly report. The practice hires no one and manages no one, and it keeps the EMR and clearinghouse it already uses. Every claim is checked against the payer's current policy before it goes out, so it holds up if the payer reviews it later, and the money stays with the practice. See how Altair runs denial management.

Primary care denials start long before the remittance: at check-in, in the AWV history and in the chart. Someone has to catch them there, on every visit, before the claim exists.

Annual wellness visit denials on a Medicare remittance

Common questions