How it works
A clinical escalation workflow designed for denial teams that need physician-level reasoning on hard cases — without replacing your internal process.
Send a de-identified case
Denial letter, relevant clinical facts, payer name. No PHI at this stage — de-identified intake is the default.
Initial fit assessment
Within 24–48 hours, Clinovian confirms whether the matter appears within scope, whether physician review may add value, what documents are required, and the appropriate paid engagement. No substantive clinical argument, pursuit recommendation, or deadline advice is provided at this stage.
Formalize engagement
If PHI is needed for the full memo, scope is confirmed and BAA executed before any protected information is transferred.
Escalation Memo delivered
Fixed 12-section Medical Necessity Escalation Memo — 48–72 hour turnaround. Handoff-ready for your appeal writer.
Pattern tagged
Every case is tagged with denial-pattern metadata. Recurring-capacity clients receive periodic denial-trend summaries. Over time, the pattern intelligence becomes as valuable as the individual memos.
What you send
- Denial letter / rationale (de-identified)
- Relevant clinical facts
- Payer name and plan type
- Denial date and appeal deadline
- Current appeal level
- Service line and claim value
What you receive
- Appealability verdict (strong / moderate / weak / not recommended)
- Criteria-mapped medical-necessity argument
- Identification of where the denial logic is weak
- Documentation gaps vs. genuine non-necessity
- Handoff-ready appeal-writer instructions
- Risk-of-failure assessment
The desk is built to catch these.
Generic clinical narrative
Describes the patient's condition without mapping to the specific criterion the payer applied. The reviewer reads it as "no new information."
Wrong appeal level argument
Level 2 and external review require materially different arguments, not reprints of Level 1. Most appeals recycle.
Missing criteria pathway
The appeal does not identify which criterion — or which threshold within that criterion — the payer used. Without that, the argument has no target.
Documentation vs. necessity confusion
The case was medically necessary but poorly documented. The appeal argues necessity when the real problem is documentation — or vice versa.
Missed comorbidity burden
Severity criteria often hinge on cumulative comorbidity impact. A single-organ-system narrative misses how multiple conditions interact to justify the level of care.
Deadline expiry
The case was clinically strong but the appeal window closed before anyone with the right clinical skill looked at it. Triage speed matters.
| Deliverable | Normal turnaround |
|---|---|
| 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 (SNF / IRF / LTACH / Home Health) | 5–7 business days |
| AI Appeal Clinical QA | 24–48 hours |
| Monthly pattern summary | Monthly |
Where Clinovian stops.
Clinovian provides:
- ✓ Physician-authored clinical reasoning
- ✓ Appealability assessment
- ✓ Criteria-style medical-necessity argument
- ✓ Documentation-gap identification
- ✓ Appeal-writer handoff instructions
- ✓ Denial-pattern intelligence
Clinovian does not:
- × Submit appeals on behalf of the client
- × Provide legal advice
- × Act as treating physician or physician of record
- × Make binding U.S. clinical determinations
- × Guarantee payer reversal or reimbursement
- × Replace certified coding professionals
Send one de-identified matter. Initial fit response 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.