Common questions about the desk.
Operational, workflow, and engagement questions we hear most often.
What exactly does my team receive?
A fixed-format Medical Necessity Escalation Memo — a 12-section physician-authored document containing: appealability verdict, payer rationale analysis, clinical evidence mapping, criteria-style argument, documentation gaps, appeal-writer instructions, and risk assessment. Each memo also includes a prevention note — a forward-looking operational insight on what documentation practice, if adopted prospectively, would reduce the likelihood of this denial type recurring. Your appeal writer uses the memo to draft or strengthen the appeal letter; your CDI team uses the prevention note to improve upstream documentation. View specimens →
What are the turnaround times?
Appealability screen: 24–48 hours. Medical Necessity Escalation Memo: 48–72 hours. P2P Prep Brief: 24–48 hours. Observation vs. Inpatient Defense: 5–7 business days. DRG-Downgrade Challenge: 7–10 business days. Post-Acute Denials: 5–7 business days. AI Appeal Clinical QA: 24–48 hours per appeal, with batch scope and service levels confirmed at intake. NSA/IDR Clinical Value Dossier: 3–5 business days after receipt of the complete agreed record, with expedited review by prior agreement. Turnarounds are commitments, not estimates — if a case will require more time due to complexity, we communicate that at the suitability stage before you commit.
How does PHI handling work?
The first step—an initial suitability review of one prospective matter—requires only de-identified information. No PHI is requested or needed. If the engagement proceeds to a full memo requiring clinical records, a Business Associate Agreement is executed before any PHI is transferred. Records are transferred through agreed secure channels only. Minimum-necessary access applies. Full security detail →
What is the clinical review structure?
Clinical escalation methodology is led by a physician with direct payer-side utilization-management review experience across 3,000+ U.S. commercial claims under licensed criteria frameworks. The desk’s output uses criteria-style reasoning mapped to the applicable payer policy, Medicare guidance, licensed criteria framework, or public clinical standard documented in the case record. The deliverable is clinical reasoning and criteria-mapped analysis for your team to use — not a licensed clinical opinion. Where a case requires formal U.S.-licensed sign-off, that stays with your own licensed clinical staff or designated reviewer. About the practice →
What happens after the 3-case evaluation?
After the evaluation, Clinovian reviews the engagement fit before proposing a Recurring Physician Review Capacity engagement. We evaluate: whether the escalated cases are genuinely physician-level, whether turnaround fits your submission timelines, documentation quality, PHI workflow requirements, escalation-routing clarity, and appropriate volume. Clients using Recurring Physician Review Capacity receive these standard inclusions: a prevention note on every memo (forward-looking documentation improvement insight), win/loss outcome tracking (60–90 day follow-up where disposition and payment data are supplied by the client, building payer-specific intelligence), and a Quarterly Impact Summary — a one-page report based on cases reviewed and outcome information supplied by the client, showing cases screened, revenue at stake, patterns identified, and prevention notes issued. Recurring pricing is scoped privately because these variables materially affect the engagement. There is no automatic rollover — you decide based on the evaluation output. Engagement detail →
Can Clinovian work white-label for our firm?
Yes. RCM firms, denial-management companies, appeal-writing firms, and AI-RCM vendors can embed the desk into their operations under white-label or co-branded terms. Your client sees your brand; Clinovian provides the physician reasoning. Partnership detail →
What types of denials are NOT suitable?
Missing-authorization denials, eligibility or coordination-of-benefits issues, coding/modifier issues with no clinical dimension, missing medical records (administrative), low-dollar routine denials, and cases where the denial is clinically correct. Clinovian does not manufacture medical necessity that the facts do not support. That selectivity is what keeps the output credible. Full suitability criteria →
What does suitability triage within a paid engagement include?
Within a paid evaluation or recurring engagement, suitability triage may categorize a case as pursue, do not pursue, or needs more information. A do-not-pursue result includes a reason category and a one-line action item: clinically correct denial (close the case), documentation gap — fixable (not appealable as documented, but includes what to document differently on future similar cases), wrong category for escalation (route to coding team), expired deadline (flag for prevention tracking), or standard-level denial (your internal team can handle this without the desk). If the denial date is included in the intake, every verdict — pursue or not — also includes an estimated appeal-deadline flag based on standard timelines for the relevant plan type and appeal level, so urgent cases are identified before the window closes. Deadline estimates should be verified with the payer. Engagement detail →
What is the pattern intelligence report?
Every case is tagged with denial-pattern metadata — payer, denial rationale type, service line, documentation gap category, criteria pathway. Recurring-capacity clients receive a summary showing recurring patterns: which payers are denying which service lines on which grounds, and where your documentation consistently falls short. Quarterly audits provide deeper trend analysis. Over time, this intelligence becomes a strategic asset — not just an operational report.
Is Clinovian a law firm?
No. Clinovian is a physician-led clinical consulting practice. Legal strategy, filing decisions, jurisdiction-specific advice, and parity enforcement (MHPAEA) remain with client counsel. The desk provides the clinical argument — the medical-necessity reasoning — that supports the legal or administrative appeal process.
How do I get started?
Send one de-identified case or dispute summary to contact@clinovian.com. No PHI and no records. Prospective clients receive one initial scope review within 24–48 hours covering service fit, whether physician review may be useful, required documents, and the appropriate paid engagement. It does not include a substantive clinical argument, pursuit recommendation, or deadline advice. Ongoing suitability triage is included within paid evaluations and recurring engagements. For partnership discussions (RCM firms, AI vendors, platform integration), schedule a 30-minute call.