When the denial is clinical, the escalation should be physician-led.
Clinovian is a physician escalation desk for the medical-necessity cases your denial team cannot resolve with templates, coding edits, or AI-generated appeal language. We take the cases your denial team escalates — and return criteria-mapped, appeal-ready clinical arguments.
Prospective clients may submit one de-identified matter for an initial fit and scope assessment.
Arguments mapped to the payer's actual decision logic — the same criteria applied on the review side.
Flat per-deliverable pricing, scoped before work begins — no running meter.
No PHI to start. A BAA is executed before any clinical record moves.
Our physician has applied InterQual and MCG criteria on the payer side of 3,000+ U.S. commercial claims — which is why the desk's arguments map to the reviewer's decision logic instead of describing the case in general clinical terms.
That operational background is what separates a criteria-mapped escalation memo from a well-written clinical narrative. It is also why the desk is built to complement your coders, CDI specialists, appeal writers, and AI appeal tools rather than compete with them — physician reasoning fills the specific gap those roles aren't built to close, and the desk hands its output back to your team rather than replacing your workflow.
Physician Clinical Escalation Services for Denial and Appeal Operations
Criteria-mapped, not narrative
There is a gap between what a coder, CDI specialist, or AI appeal tool can argue — and what requires genuine physician-level medical-necessity reasoning. That gap is the desk, organized below by who sends the case.
The same clinical QA layer reaches your denial team and your AI vendor from opposite ends of the same workflow — independent physician review, not a competing appeal service.
Validate AI-drafted appeals before they reach the payer.
Catch hallucinated claims and weak criteria logic before submission — not after a second denial.
Embed physician QA into your pipeline.
A pre-submission checkpoint, not a parallel workflow. Per-batch or retainer.
See exactly what your appeal writer receives.
Every memo maps the denied service to the specific criterion the payer reviewer applied — line by line, not as a clinical summary. Real memos cover the full case; this is the reasoning excerpt.
Not sure if your case belongs on the desk?
Prospective clients may send one de-identified case or dispute summary—no records and no PHI. Clinovian returns an initial fit response covering scope, potential value of physician review, required documents, and the appropriate paid engagement.
Defined physician deliverables—not open-ended hours.
3-Case Denial Evaluation
Three standard-scope denial cases reviewed by physician. Full deliverable, criteria mapping, pattern summary, and findings discussion.
3-Dossier IDR Evaluation
Three standard-scope, clinically distinct Federal IDR dossiers with physician-authored clinical synthesis.
Recurring Physician Review Capacity
From five deliverables per month with pattern intelligence, outcome tracking where data is supplied, and Quarterly Impact Summary. White-label available.
Six Failure Modes of Clinical Denial Appeals
A physician reviewer's reference on why most medical-necessity appeals fail — and the patterns behind it.
Read the Field Guide →Physician-level clinical escalation, on a fixed cycle you can plan around.
Prospective clients may begin with one de-identified scope review. Substantive clinical work begins only after scope and fee are confirmed.
De-identified denial rationale
No PHI. No records. Just the denial reason, service type, and payer. Email or form.
Initial fit assessment
Confirms scope, whether physician review may be useful, required documents, and the appropriate paid engagement. No substantive argument or deadline advice.
BAA + records transfer
BAA executed. Clinical records transferred through secure channels. Minimum-necessary access.
Physician Escalation Memo delivered
Fixed 12-section deliverable. Criteria-mapped argument. Appeal-writer instructions. Fixed fee per agreed scope.
The initial scope review is limited to one de-identified matter for prospective clients. Suitability triage for ongoing cases is included within paid evaluation and recurring-capacity engagements.
Send one de-identified matter. Receive an initial fit assessment in 24–48 hours.
No PHI and no commitment. The initial scope review confirms fit and fee; substantive clinical work begins under an agreed paid engagement.