SYNTHETIC POLICY CONTEXT

No real payer policy is supplied in this folder. Clinical coverage, coding correctness and filing
exceptions all require qualified review. Contract rates here are fictional.

WHAT THE SOURCE FILES DO NOT CONTAIN, ON PURPOSE
Denial family. Expected allowed amount. Variance against contract. Recovery probability. Expected
value. Filing or appeal deadline. Route recommendation. Root cause. Every one of those is derived,
and a source file that shipped them would mean the platform was reading an answer key rather than
deriving anything.

CO-45 IS NOT A DENIAL
CO-45 is the contractual fee-schedule adjustment and is the most frequent code in this folder. It
appears on nearly every adjudicated claim, including every correctly paid one. Counting it as a
denial would make the denial count absurd. An underpayment is found by comparing the amount paid
against the contracted rate for the service date, not by observing a CO-45.

PR AND OA ARE NOT PAYER RECOVERABLE
A PR group code is patient responsibility. An OA group code belongs to another payer. Neither is
recoverable from the payer named on the remittance, however large. PR-27 in particular appears in
hospital denial reports and is entirely patient liability.
