Methodology & Research
Health Revenue Intelligence (HRI) scores every open claim so follow-up starts with the money most likely to come back. Each score draws on what we track about how payers pay.
Methodology
Every open claim gets a recoverability score from likelihood of payment, dollar value, payer behavior and effort to resolve. The score drives the Fix & Revenue Queue, the work list where the highest-value, most-winnable claims come first.
Scope & limitations. Applies to open behavioral-health claims under active follow-up. A high score prioritizes work on the available evidence and does not predict or guarantee payment. A low score may reflect missing information rather than a claim that is truly unrecoverable. Scores are estimates, and they depend on data quality and payer behavior.
Put the score on your claims →Denial reason, payer pattern, timing.
Expected collectible vs. contracted.
Historical responsiveness & friction.
Steps, documentation, turnaround.
Diagnostic Framework
The 7-Point Diagnostic applies seven checkpoints to every stuck claim. We verify claim-build integrity before we assign a problem to the payer.
Rejection Code
ERA / Remittance
Claim History
Payer Relationship
Provider Enrollment
Code Integrity
Claim Build
Payer behavior we track
The gap between a plan's policy and the way it pays is where recovery happens. We track what a plan delays, how it routes money and the errors it makes.
When a provider does not enroll in Optum Pay ACH, UnitedHealthcare defaults them to virtual card payments that can carry card-processing fees on every remittance. Electing ACH, a direct bank deposit, stops those fees.
When a carrier trims out-of-network coverage, the change may reach only its fully insured plans, where the payer carries the risk. Self-funded employer plans are paid for by the employer and administered by the carrier or a third-party administrator, so the same member may still have benefits. Whether a patient holds a fully insured or a self-funded plan changes how we work the claim.
We watch for payer system errors as well as individual denials. One carrier's system started reading an IOP code (intensive outpatient) as its higher-authorization version and denying for no authorization. Those claims reprocessed on resubmission, with no claim-by-claim appeals.
Many carriers and Medicaid plans hand behavioral health to a separate manager, such as Optum, Carelon, or Magellan. We confirm who processes the claim at eligibility, before submission. That heads off a whole category of routing denials.
Payer intelligence means knowing how a plan will behave before you submit. Explore HRI Insights →
From the desk
Dated observations from the claims we work, with patterns worth checking in your own claims. Never client information, never a payer policy statement.
Jul 19, 2026
PB
On out-of-network residential claims we keep finding UnitedHealthcare-administered plans, UMR included, either parking claims in post-service review or issuing payment to the member instead of the facility. If the portal says paid and no deposit ever landed, ask the family before you write an appeal — the check may be sitting in their mailbox.
Jul 19, 2026
PB
Several aged-receivable recoveries this month show the same shape: claims that were fixable, sitting in 'follow-up' while filing and appeal windows closed on part of the balance. Pull the 120-day-plus aging and check every payer's filing clock against it this week. The recoverable tail shrinks monthly, and it never announces itself.
Jul 15, 2026
CR
We traced one program's missing Blue-plan revenue to an enrollment gap that let institutional claims clear the clearinghouse and die quietly at the payer's front end. Nothing looked wrong until the aging did. If claims go out and no rejection ever comes back, treat the silence as the alarm.
Methodology v1.0
The seven checkpoints and the four scoring inputs stay the same from claim to claim.
How the method holds up
We score each open behavioral-health claim under active follow-up on four inputs: payment likelihood, dollar value, payer behavior and effort to resolve. The score sets the order of the Fix & Revenue Queue, our work list.
No. The score ranks claims for follow-up and guarantees nothing about payment. A low score can mean information is missing rather than that the money is gone.
We check the claim itself first. Our diagnostic looks at seven points: rejection code, remittance, claim history, payer relationship, provider enrollment, code integrity and claim build. Only then do we treat the problem as the payer's.
It means knowing how a plan pays before a claim goes out. That includes whether it defaults to virtual card payment unless you elect ACH, whether the plan is self-funded and who processes its behavioral health claims.
It is written down. The claim scoring runs on Methodology v1.0, authored and reviewed by the HRI partners, and its calibration is revisited as outcome data grows.
Want the methodology applied to your claims?
The review starts with a few lines about your claims and payers. We baseline your open claims, score what is recoverable and show you which ones are worth working first.
Please keep patient data off the review form. We ask for secure information only after intake and contracting.
Last updated: October 25, 2026