Denial Analysis KPIs & Reporting
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Denial Analysis KPIs & Reporting

KPI Summary

KPI ID KPI Name Formula (Conceptual) Target Data Source Frequency
KPI-DEN-001 Overall Denial Rate (Number of denied claims ÷ total submitted claims) × 100 ≤ 5% denial_records, claims Monthly / Weekly
KPI-DEN-002 Denial Rate by Category (Denied claims in category ÷ total submitted claims) × 100 Eligibility ≤ 1%, Auth ≤ 1%, Coding ≤ 2% denial_records, denial_categories, claims Monthly
KPI-DEN-003 Appeal Rate (Denials appealed ÷ total denials) × 100 ≥ 80% of appealable denials denial_records, appeals Monthly
KPI-DEN-004 Appeal Success Rate (Appeals overturned ÷ total resolved appeals) × 100 ≥ 50% appeal_outcomes Monthly
KPI-DEN-005 Denial Recovery Rate (Recovered amount ÷ denied amount) × 100 ≥ 60% denial_records, appeal_outcomes Monthly
KPI-DEN-006 Average Days to Appeal Average(appeal submission date − denial date) ≤ 10 days denial_records, appeals Weekly / Monthly
KPI-DEN-007 Avg Appeal Resolution Time Average(appeal resolution date − appeal submission date) ≤ 30 days appeals, appeal_outcomes Monthly
KPI-DEN-008 Preventable Denial Rate (Preventable denials ÷ total denials) × 100 ≤ 50% with declining trend denial_records, denial_root_causes Monthly / Quarterly
KPI-DEN-009 Denial Write-Off Amount Sum(denied amount where resolution type = write-off) Declining QoQ denial_records Monthly / Quarterly
KPI-DEN-010 Prevention Action ROI ((Reduction in denied amount − implementation cost) ÷ implementation cost) × 100 ≥ 200% denial_prevention_actions, denial_trends Quarterly / Annually

Note: Actual table/field names align with the 03-data-specifications for the denial-analysis module.

KPI Definitions

KPI-DEN-001: Overall Denial Rate

a. Definition

Percentage of all submitted claims that result in at least one denial (full or partial). Indicates overall effectiveness of the revenue cycle from registration through billing. Used by Denial Manager and Revenue Cycle Manager to monitor performance and benchmark against UAE private and governmental payer expectations.

b. Calculation Formula

  • Level: Claim-level (a claim is counted as denied if it has ≥1 associated denial record in the period).
SQL
-- Overall Denial Rate (%) by month and facility
SELECT
    c.facility_id,
    DATE_TRUNC('month', c.submission_date) AS period_start,
    COUNT(DISTINCT c.claim_id) AS total_submitted_claims,
    COUNT(DISTINCT CASE WHEN dr.denial_id IS NOT NULL THEN c.claim_id END) AS denied_claims,
    COUNT(DISTINCT CASE WHEN dr.denial_id IS NOT NULL THEN c.claim_id END) * 100.0
        / NULLIF(COUNT(DISTINCT c.claim_id), 0) AS overall_denial_rate_pct
FROM billing_claims.claims c
LEFT JOIN denial_analysis.denial_records dr
    ON dr.claim_id = c.claim_id
    AND dr.denial_date BETWEEN :start_date AND :end_date
WHERE c.submission_date BETWEEN :start_date AND :end_date
GROUP BY c.facility_id, DATE_TRUNC('month', c.submission_date)
ORDER BY period_start, facility_id;

c. Target / Benchmark

Metric Target Source / Rationale
Overall Denial Rate ≤ 5% Common GCC private hospital benchmark; supports DOH/DHA revenue integrity goals

d. Data Source

  • billing_claims.claims
  • claim_id, facility_id, payer_id, submission_date, total_claim_amount
  • denial_analysis.denial_records
  • denial_id, claim_id, denial_date

e. Dimensions / Filters

  • Time: day, week, month, quarter, year
  • Facility: claims.facility_id
  • Department: via claims.department_id or linked encounters.department_id
  • Provider: via claims.attending_provider_id
  • Payer: claims.payer_id
  • Claim type: inpatient / outpatient / day surgery

f. Visualization

  • Primary: Line chart (monthly trend) with target line at 5%
  • Secondary: Bar chart (denial rate by payer, by department)
  • Drill-down: Table of top denied claims by amount

g. Alert Thresholds

  • Warning: Denial rate > 5% for 2 consecutive months
  • Critical: Denial rate > 8% in any month or > 6% for 3 consecutive months
  • Notification recipients:
  • Denial Manager
  • Revenue Cycle Manager
  • Facility Finance Director (for critical)

KPI-DEN-002: Denial Rate by Category

a. Definition

Percentage of submitted claims that are denied for each standard denial category (eligibility, authorization, coding, medical necessity, timely filing, duplicate, bundling, etc.). Identifies where process failures are concentrated.

b. Calculation Formula

SQL
-- Denial Rate by Category (%) by month and payer
SELECT
    c.facility_id,
    drc.category_id,
    dc.category_name,
    c.payer_id,
    DATE_TRUNC('month', c.submission_date) AS period_start,
    COUNT(DISTINCT c.claim_id) AS total_submitted_claims,
    COUNT(DISTINCT CASE WHEN dr.denial_id IS NOT NULL THEN c.claim_id END) AS denied_claims_in_category,
    COUNT(DISTINCT CASE WHEN dr.denial_id IS NOT NULL THEN c.claim_id END) * 100.0
        / NULLIF(COUNT(DISTINCT c.claim_id), 0) AS denial_rate_category_pct
FROM billing_claims.claims c
LEFT JOIN denial_analysis.denial_records dr
    ON dr.claim_id = c.claim_id
    AND dr.denial_date BETWEEN :start_date AND :end_date
LEFT JOIN denial_analysis.denial_categories dc
    ON dc.category_id = dr.denial_category_id
WHERE c.submission_date BETWEEN :start_date AND :end_date
GROUP BY c.facility_id, drc.category_id, dc.category_name, c.payer_id, DATE_TRUNC('month', c.submission_date)
ORDER BY period_start, facility_id, category_name, payer_id;

(If multiple categories per claim, each category is counted separately; denominator remains total submitted claims.)

c. Target / Benchmark

Category Target Denial Rate Rationale
Eligibility ≤ 1% Front-end eligibility checks (Patient Access) should prevent most denials
Authorization ≤ 1% Pre-auth workflows and DOH/DHA rules
Coding ≤ 2% Mature coding quality program using ICD-10-AM & CPT
Timely filing 0%–0.5% Fully preventable with system alerts
Duplicate ≤ 0.5% Preventable via billing edits
Medical necessity Facility-defined Depends on payer policies; monitored for trend

d. Data Source

  • billing_claims.claims
  • claim_id, facility_id, payer_id, submission_date
  • denial_analysis.denial_records
  • denial_id, claim_id, denial_category_id, denial_date
  • denial_analysis.denial_categories
  • category_id, category_name, category_group, responsible_department

e. Dimensions / Filters

  • Time: month, quarter, year
  • Facility, department, provider
  • Payer, plan
  • Category group (front-end / mid-cycle / back-end)
  • Claim type (IP/OP)

f. Visualization

  • Stacked bar chart: denial rate by category per month
  • Heatmap: category vs payer (denial rate)
  • Pareto chart: top categories by financial impact

g. Alert Thresholds

  • Warning:
  • Eligibility or authorization denial rate > 1% for any payer
  • Coding denial rate > 2.5%
  • Critical:
  • Timely filing denials > 0.5% overall
  • Any category rate doubles vs previous quarter
  • Notification:
  • Denial Manager
  • Patient Access Manager (for eligibility/auth)
  • Coding Manager (for coding/medical necessity)
  • Billing Manager (for timely filing/duplicate)

KPI-DEN-003: Appeal Rate

a. Definition

Percentage of denials that have at least one appeal submitted. Measures how effectively appealable denials are being worked.

b. Calculation Formula

SQL
-- Appeal Rate (%) by month and payer
SELECT
    dr.facility_id,
    dr.payer_id,
    DATE_TRUNC('month', dr.denial_date) AS period_start,
    COUNT(DISTINCT dr.denial_id) AS total_denials,
    COUNT(DISTINCT CASE WHEN a.appeal_id IS NOT NULL THEN dr.denial_id END) AS denials_appealed,
    COUNT(DISTINCT CASE WHEN a.appeal_id IS NOT NULL THEN dr.denial_id END) * 100.0
        / NULLIF(COUNT(DISTINCT dr.denial_id), 0) AS appeal_rate_pct
FROM denial_analysis.denial_records dr
LEFT JOIN denial_analysis.appeals a
    ON a.denial_id = dr.denial_id
    AND a.submission_date BETWEEN :start_date AND :end_date
WHERE dr.denial_date BETWEEN :start_date AND :end_date
  AND dr.status IN ('open', 'in_appeal', 'resolved')  -- exclude cancelled if needed
  AND dr.is_appealable = TRUE                         -- optional flag if available
GROUP BY dr.facility_id, dr.payer_id, DATE_TRUNC('month', dr.denial_date)
ORDER BY period_start, facility_id, payer_id;

c. Target / Benchmark

Metric Target Rationale
Appeal Rate ≥ 80% For denials classified as appealable by denial analysts

d. Data Source

  • denial_analysis.denial_records
  • denial_id, facility_id, payer_id, denial_date, status, is_appealable (if implemented)
  • denial_analysis.appeals
  • appeal_id, denial_id, submission_date, appeal_level, status

e. Dimensions / Filters

  • Time: month, quarter
  • Facility, department
  • Payer, plan
  • Denial category
  • Appeal level (first, second, external)

f. Visualization

  • Bar chart: appeal rate by payer and category
  • Line chart: overall appeal rate trend
  • Table: list of high-value unappealed denials

g. Alert Thresholds

  • Warning: Appeal rate < 80% for high-value denials (e.g., > AED 5,000)
  • Critical: Appeal rate < 60% overall or for any major payer (THIQA, Daman, Oman Insurance)
  • Notification:
  • Denial Manager
  • Senior Denial Analysts

KPI-DEN-004: Appeal Success Rate

a. Definition

Percentage of resolved appeals where the payer decision is overturned (full or partial in favour of the provider). Indicates effectiveness of appeal documentation and strategy.

b. Calculation Formula

SQL
-- Appeal Success Rate (%) by month and payer
SELECT
    a.facility_id,
    a.payer_id,
    DATE_TRUNC('month', ao.response_date) AS period_start,
    COUNT(DISTINCT a.appeal_id) AS total_resolved_appeals,
    COUNT(DISTINCT CASE WHEN ao.payer_decision = 'overturned' THEN a.appeal_id END) AS appeals_overturned,
    COUNT(DISTINCT CASE WHEN ao.payer_decision = 'overturned' THEN a.appeal_id END) * 100.0
        / NULLIF(COUNT(DISTINCT a.appeal_id), 0) AS appeal_success_rate_pct
FROM denial_analysis.appeals a
JOIN denial_analysis.appeal_outcomes ao
    ON ao.appeal_id = a.appeal_id
WHERE ao.response_date BETWEEN :start_date AND :end_date
  AND ao.final_resolution = TRUE
GROUP BY a.facility_id, a.payer_id, DATE_TRUNC('month', ao.response_date)
ORDER BY period_start, facility_id, payer_id;

c. Target / Benchmark

Metric Target Rationale
Appeal Success Rate ≥ 50% Common benchmark for well-managed denial programs

d. Data Source

  • denial_analysis.appeals
  • appeal_id, denial_id, facility_id, payer_id, submission_date
  • denial_analysis.appeal_outcomes
  • outcome_id, appeal_id, response_date, payer_decision (overturned, upheld, partial), final_resolution, recovered_amount

e. Dimensions / Filters

  • Time: month, quarter
  • Facility
  • Payer, plan
  • Denial category
  • Appeal level
  • Assigned analyst

f. Visualization

  • Bar chart: success rate by payer and appeal level
  • Line chart: trend of success rate over time
  • Table: top successful appeal reasons/templates

g. Alert Thresholds

  • Warning: Success rate < 50% overall or for any top 5 payer
  • Critical: Success rate < 35% for two consecutive quarters
  • Notification:
  • Denial Manager
  • Revenue Cycle Manager
  • Coding Specialist Lead (for coding-related denials)

KPI-DEN-005: Denial Recovery Rate

a. Definition

Percentage of denied amount that is recovered through appeals, corrected claims, or other follow-up actions. Reflects financial effectiveness of denial management.

b. Calculation Formula

SQL
-- Denial Recovery Rate (%) by month and payer
SELECT
    dr.facility_id,
    dr.payer_id,
    DATE_TRUNC('month', dr.denial_date) AS period_start,
    SUM(dr.denied_amount) AS total_denied_amount,
    SUM(COALESCE(dr.recovered_amount, 0)) AS total_recovered_amount,
    SUM(COALESCE(dr.recovered_amount, 0)) * 100.0
        / NULLIF(SUM(dr.denied_amount), 0) AS denial_recovery_rate_pct
FROM denial_analysis.denial_records dr
WHERE dr.denial_date BETWEEN :start_date AND :end_date
GROUP BY dr.facility_id, dr.payer_id, DATE_TRUNC('month', dr.denial_date)
ORDER BY period_start, facility_id, payer_id;

(If recovered amount is stored in appeal_outcomes, join and sum there instead.)

c. Target / Benchmark

Metric Target Rationale
Denial Recovery Rate ≥ 60% Aggressive but achievable for UAE private hospitals

d. Data Source

  • denial_analysis.denial_records
  • denial_id, facility_id, payer_id, denied_amount, recovered_amount, denial_date
  • Optionally denial_analysis.appeal_outcomes.recovered_amount if more granular

e. Dimensions / Filters

  • Time: month, quarter, year
  • Facility
  • Payer, plan
  • Denial category
  • Appeal level
  • High-value vs low-value denials

f. Visualization

  • Gauge: overall recovery rate vs 60% target
  • Bar chart: recovery rate by payer and category
  • Trend line: recovery rate over time

g. Alert Thresholds

  • Warning: Recovery rate < 60% overall or for any major payer
  • Critical: Recovery rate < 50% for two consecutive quarters
  • Notification:
  • Denial Manager
  • Revenue Cycle Manager
  • Finance Director

KPI-DEN-006: Average Days to Appeal

a. Definition

Average number of calendar days between denial date and first appeal submission date. Measures timeliness of appeal initiation relative to payer deadlines (as per DOH/DHA payer contracts).

b. Calculation Formula

SQL
-- Average Days to Appeal by month and payer
SELECT
    dr.facility_id,
    dr.payer_id,
    DATE_TRUNC('month', dr.denial_date) AS period_start,
    AVG(DATE_PART('day', a.submission_date::timestamp - dr.denial_date::timestamp)) AS avg_days_to_appeal
FROM denial_analysis.denial_records dr
JOIN denial_analysis.appeals a
    ON a.denial_id = dr.denial_id
    AND a.appeal_level = 1  -- first-level appeal
WHERE dr.denial_date BETWEEN :start_date AND :end_date
GROUP BY dr.facility_id, dr.payer_id, DATE_TRUNC('month', dr.denial_date)
ORDER BY period_start, facility_id, payer_id;

c. Target / Benchmark

Metric Target Rationale
Average Days to Appeal ≤ 10 days Ensures compliance with typical UAE payer appeal deadlines (30–60 days)

d. Data Source

  • denial_analysis.denial_records
  • denial_id, facility_id, payer_id, denial_date
  • denial_analysis.appeals
  • appeal_id, denial_id, submission_date, appeal_level

e. Dimensions / Filters

  • Time: month, quarter
  • Facility
  • Payer
  • Denial category
  • Appeal level
  • Assigned analyst

f. Visualization

  • Line chart: average days to appeal over time
  • Box plot: distribution by payer
  • Table: list of denials approaching appeal deadline (using Appeal Deadline Rules master data)

g. Alert Thresholds

  • Warning: Average days to appeal > 10 days for any payer
  • Critical:
  • Any denials with days remaining to deadline < 7 and no appeal submitted
  • Notification:
  • Denial Analysts (worklist alerts)
  • Denial Manager (summary)

KPI-DEN-007: Average Appeal Resolution Time

a. Definition

Average number of days from appeal submission to payer response (final resolution). Indicates payer responsiveness and helps set expectations for cash flow.

b. Calculation Formula

SQL
-- Average Appeal Resolution Time (days) by month and payer
SELECT
    a.facility_id,
    a.payer_id,
    DATE_TRUNC('month', a.submission_date) AS period_start,
    AVG(DATE_PART('day', ao.response_date::timestamp - a.submission_date::timestamp)) AS avg_resolution_days
FROM denial_analysis.appeals a
JOIN denial_analysis.appeal_outcomes ao
    ON ao.appeal_id = a.appeal_id
WHERE ao.response_date BETWEEN :start_date AND :end_date
  AND ao.final_resolution = TRUE
GROUP BY a.facility_id, a.payer_id, DATE_TRUNC('month', a.submission_date)
ORDER BY period_start, facility_id, payer_id;

c. Target / Benchmark

Metric Target Rationale
Avg Appeal Resolution Time ≤ 30 days Aligns with typical UAE payer SLAs

d. Data Source

  • denial_analysis.appeals
  • appeal_id, denial_id, facility_id, payer_id, submission_date
  • denial_analysis.appeal_outcomes
  • outcome_id, appeal_id, response_date, final_resolution

e. Dimensions / Filters

  • Time: month, quarter
  • Facility
  • Payer
  • Appeal level
  • Denial category

f. Visualization

  • Bar chart: average resolution days by payer
  • Line chart: trend over time
  • Table: outlier appeals exceeding payer SLA

g. Alert Thresholds

  • Warning: Average resolution time > 30 days for any payer
  • Critical: > 45 days for two consecutive months for a major payer
  • Notification:
  • Denial Manager
  • Policy & Contract Management team (for payer escalation)

KPI-DEN-008: Preventable Denial Rate

a. Definition

Percentage of denials classified as preventable based on root cause analysis (e.g., missing authorization, incorrect eligibility, coding errors). Used to drive process improvement and training.

b. Calculation Formula

SQL
-- Preventable Denial Rate (%) by month and category
SELECT
    dr.facility_id,
    dr.payer_id,
    DATE_TRUNC('month', dr.denial_date) AS period_start,
    COUNT(dr.denial_id) AS total_denials,
    COUNT(CASE WHEN dr.is_preventable = TRUE THEN dr.denial_id END) AS preventable_denials,
    COUNT(CASE WHEN dr.is_preventable = TRUE THEN dr.denial_id END) * 100.0
        / NULLIF(COUNT(dr.denial_id), 0) AS preventable_denial_rate_pct
FROM denial_analysis.denial_records dr
WHERE dr.denial_date BETWEEN :start_date AND :end_date
GROUP BY dr.facility_id, dr.payer_id, DATE_TRUNC('month', dr.denial_date)
ORDER BY period_start, facility_id, payer_id;

c. Target / Benchmark

Metric Target Rationale
Preventable Denial Rate ≤ 50% with declining trend Many denials are process-driven and avoidable

d. Data Source

  • denial_analysis.denial_records
  • denial_id, facility_id, payer_id, denial_date, is_preventable, denial_category_id
  • denial_analysis.denial_root_causes
  • root_cause_id, denial_id, root_cause_category, process_failure_point

e. Dimensions / Filters

  • Time: month, quarter, year
  • Facility, department
  • Payer
  • Denial category
  • Process stage (front-end / mid-cycle / back-end)

f. Visualization

  • Stacked bar: preventable vs non-preventable denials by category
  • Heatmap: preventable rate by department and payer
  • Trend line: preventable rate over time

g. Alert Thresholds

  • Warning: Preventable rate > 50% overall or rising for 2 consecutive quarters
  • Critical: Preventable rate > 60% in any major department (e.g., surgery, medicine)
  • Notification:
  • Denial Manager
  • Department Heads
  • Revenue Cycle Manager

KPI-DEN-009: Denial Write-Off Amount

a. Definition

Total amount of denied charges written off (i.e., not recovered and not billed to patient) in the period. Represents direct revenue loss due to denials.

b. Calculation Formula

SQL
-- Denial Write-Off Amount (AED) by month and facility
SELECT
    dr.facility_id,
    DATE_TRUNC('month', dr.resolution_date) AS period_start,
    SUM(dr.denied_amount) AS total_write_off_amount
FROM denial_analysis.denial_records dr
WHERE dr.resolution_date BETWEEN :start_date AND :end_date
  AND dr.resolution_type = 'write_off'
GROUP BY dr.facility_id, DATE_TRUNC('month', dr.resolution_date)
ORDER BY period_start, facility_id;

c. Target / Benchmark

Metric Target Rationale
Denial Write-Off Amount Declining trend QoQ Continuous improvement expectation

d. Data Source

  • denial_analysis.denial_records
  • denial_id, facility_id, resolution_date, resolution_type, denied_amount
  • denial_analysis.denial_categories (for breakdown by category)
  • policy-contract-mgmt.write_off_approval_thresholds (master data, if implemented)

e. Dimensions / Filters

  • Time: month, quarter, year
  • Facility
  • Payer
  • Denial category
  • Department
  • Approval level / approver

f. Visualization

  • Line chart: write-off amount trend
  • Bar chart: write-off amount by payer and category
  • Table: top 50 write-offs with reason and approver

g. Alert Thresholds

  • Warning: Write-off amount increases > 10% vs previous quarter
  • Critical:
  • Single write-off > configured threshold (e.g., AED 50,000) without appropriate approval
  • Notification:
  • Denial Manager
  • Finance Director
  • Internal Audit (for critical outliers)

KPI-DEN-010: Prevention Action ROI

a. Definition

Return on investment for denial prevention actions (e.g., training, system rule changes). Compares reduction in denied amount attributable to the action vs implementation cost.

b. Calculation Formula

Assumes denial_prevention_actions stores pre/post denial rates and cost, and denial_trends stores denied amounts per period/category.

SQL
-- Prevention Action ROI (%) per action
SELECT
    dpa.action_id,
    dpa.description,
    dpa.denial_category_id,
    dpa.payer_id,
    dpa.implementation_cost,
    (dpa.reduction_in_denied_amount - dpa.implementation_cost) * 100.0
        / NULLIF(dpa.implementation_cost, 0) AS prevention_action_roi_pct
FROM denial_analysis.denial_prevention_actions dpa
WHERE dpa.completion_date BETWEEN :start_date AND :end_date;

If reduction is not stored, it can be computed from denial_trends (pre vs post periods) in a more complex query.

c. Target / Benchmark

Metric Target Rationale
Prevention Action ROI ≥ 200% Only high-value initiatives should scale

d. Data Source

  • denial_analysis.denial_prevention_actions
  • action_id, denial_category_id, payer_id, description, action_type, implementation_cost, reduction_in_denied_amount, completion_date
  • denial_analysis.denial_trends
  • trend_id, period_start, period_end, payer_id, denial_category_id, denied_amount, denial_count

e. Dimensions / Filters

  • Time: completion date, evaluation period
  • Facility (if stored)
  • Payer
  • Denial category
  • Action type (training, system change, process change)
  • Responsible party

f. Visualization

  • Bar chart: ROI by action
  • Bubble chart: ROI vs implementation cost vs denied amount reduction
  • Table: ranked list of actions with ROI and status

g. Alert Thresholds

  • Warning: Any completed action with ROI < 100%
  • Critical: Portfolio average ROI < 150% over a year
  • Notification:
  • Denial Manager
  • Revenue Cycle Manager
  • Finance Director

Standard Reports

Report ID Report Name Purpose Audience Frequency Format
RPT-DEN-001 Denial Overview Dashboard High-level view of overall denial rate, recovery, and financial impact Denial Manager, RCM Manager, C-Suite Real-time / Daily Interactive dashboard (HTML)
RPT-DEN-002 Denial Category Analysis Analyze denials by category, department, provider, and payer Denial Analysts, Department Heads Weekly / Monthly Dashboard + Excel export
RPT-DEN-003 Appeal Performance Report Track appeal rate, success rate, and resolution time Denial Analysts, Senior Analysts Monthly PDF + Excel
RPT-DEN-004 Payer Denial Scorecard Compare payer performance and support contract negotiations Denial Manager, Policy & Contract Team Monthly / Quarterly Dashboard + PDF
RPT-DEN-005 High-Value Denials & Write-Offs Identify large denials and write-offs for review Finance Director, Internal Audit Monthly PDF + Excel
RPT-DEN-006 Preventable Denials & Root Causes Highlight preventable denials and underlying process issues Denial Manager, Dept Heads Monthly / Quarterly Dashboard + Excel
RPT-DEN-007 Denial Prevention Action Tracker Monitor status and ROI of prevention actions Denial Manager, RCM Manager Monthly Dashboard
RPT-DEN-008 DOH/DHA Denial Statistics Extract Provide standardized denial statistics for DOH/DHA reporting Compliance, RCM Manager Monthly / Quarterly CSV / XML per regulator spec
RPT-DEN-009 PDPL Access & Audit Log (Denials) Evidence of access control and audit trail for denial data DPO, Compliance Officer Quarterly / On-demand PDF + CSV
RPT-DEN-010 NABIDH/Malaffi Denial Quality Report Support HIE-related quality and utilization metrics Quality & Informatics Quarterly CSV / Dashboard

Dashboard Wireframe

Denial Trend Dashboard (SCR-DEN-004 + KPIs)

Show HTML code
HTML
<div style="font-family: Arial, sans-serif; padding: 16px; background:#f5f5f5;">
  <!-- Filters -->
  <div style="background:#ffffff; padding:12px; margin-bottom:12px; border-radius:4px;">
    <strong>Filters:</strong>
    <label style="margin-left:12px;">Date Range:
      <select>
        <option>Last 30 days</option>
        <option>Last 90 days</option>
        <option>Year to Date</option>
        <option>Custom…</option>
      </select>
    </label>
    <label style="margin-left:12px;">Facility:
      <select>
        <option>All Facilities</option>
        <option>Dubai General Hospital</option>
        <option>Abu Dhabi Medical Center</option>
      </select>
    </label>
    <label style="margin-left:12px;">Payer:
      <select>
        <option>All Payers</option>
        <option>THIQA</option>
        <option>Daman</option>
        <option>Oman Insurance</option>
      </select>
    </label>
    <label style="margin-left:12px;">Department:
      <select>
        <option>All</option>
        <option>Medicine</option>
        <option>Surgery</option>
        <option>Emergency</option>
      </select>
    </label>
  </div>

  <!-- KPI Cards -->
  <div style="display:flex; gap:12px; margin-bottom:12px;">
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px;">
      <div style="font-size:12px; color:#666;">Overall Denial Rate</div>
      <div style="font-size:24px; font-weight:bold;">4.3%</div>
      <div style="font-size:11px; color:#0a0;">▼ 0.5% vs last month</div>
    </div>
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px;">
      <div style="font-size:12px; color:#666;">Denial Recovery Rate</div>
      <div style="font-size:24px; font-weight:bold;">62%</div>
      <div style="font-size:11px; color:#0a0;">▲ 3% vs last month</div>
    </div>
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px;">
      <div style="font-size:12px; color:#666;">Preventable Denial Rate</div>
      <div style="font-size:24px; font-weight:bold;">48%</div>
      <div style="font-size:11px; color:#f60;">▼ 2% vs last quarter</div>
    </div>
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px;">
      <div style="font-size:12px; color:#666;">Denial Write-Off (AED)</div>
      <div style="font-size:24px; font-weight:bold;">1,250,000</div>
      <div style="font-size:11px; color:#c00;">▲ 8% vs last quarter</div>
    </div>
  </div>

  <!-- Charts Row 1 -->
  <div style="display:flex; gap:12px; margin-bottom:12px;">
    <div style="flex:2; background:#ffffff; padding:10px; border-radius:4px; height:260px;">
      <div style="font-size:13px; font-weight:bold; margin-bottom:4px;">Denial Rate Trend</div>
      <div style="font-size:11px; color:#666; margin-bottom:4px;">Monthly overall denial rate vs 5% target</div>
      <div style="border:1px solid #ddd; height:210px; text-align:center; padding-top:90px; color:#999;">
        [Line Chart Placeholder]
      </div>
    </div>
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px; height:260px;">
      <div style="font-size:13px; font-weight:bold; margin-bottom:4px;">Denial Rate by Category</div>
      <div style="border:1px solid #ddd; height:210px; text-align:center; padding-top:90px; color:#999;">
        [Stacked Bar Chart Placeholder]
      </div>
    </div>
  </div>

  <!-- Charts Row 2 -->
  <div style="display:flex; gap:12px; margin-bottom:12px;">
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px; height:260px;">
      <div style="font-size:13px; font-weight:bold; margin-bottom:4px;">Payer Comparison</div>
      <div style="border:1px solid #ddd; height:210px; text-align:center; padding-top:90px; color:#999;">
        [Bar Chart: Denial & Recovery Rate by Payer]
      </div>
    </div>
    <div style="flex:1; background:#ffffff; padding:10px; border-radius:4px; height:260px;">
      <div style="font-size:13px; font-weight:bold; margin-bottom:4px;">Appeal Performance</div>
      <div style="border:1px solid #ddd; height:210px; text-align:center; padding-top:90px; color:#999;">
        [Dual Axis: Appeal Rate & Success Rate]
      </div>
    </div>
  </div>

  <!-- Detail Table -->
  <div style="background:#ffffff; padding:10px; border-radius:4px;">
    <div style="display:flex; justify-content:space-between; align-items:center;">
      <div style="font-size:13px; font-weight:bold;">Top Denial Categories (by Financial Impact)</div>
      <div>
        <button style="font-size:11px; padding:4px 8px;">Export CSV</button>
        <button style="font-size:11px; padding:4px 8px;">Export Excel</button>
      </div>
    </div>
    <table style="width:100%; border-collapse:collapse; margin-top:6px; font-size:11px;">
      <thead>
        <tr>
          <th style="border-bottom:1px solid #ccc; text-align:left;">Category</th>
          <th style="border-bottom:1px solid #ccc; text-align:right;">Denied Amount (AED)</th>
          <th style="border-bottom:1px solid #ccc; text-align:right;">Preventable %</th>
          <th style="border-bottom:1px solid #ccc; text-align:right;">Appeal Success %</th>
          <th style="border-bottom:1px solid #ccc; text-align:right;">Write-Off (AED)</th>
          <th style="border-bottom:1px solid #ccc; text-align:left;">Action Status</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <td>Authorization</td>
          <td style="text-align:right;">450,000</td>
          <td style="text-align:right;">72%</td>
          <td style="text-align:right;">58%</td>
          <td style="text-align:right;">120,000</td>
          <td>Training in progress (due 30-Mar)</td>
        </tr>
        <tr>
          <td>Eligibility</td>
          <td style="text-align:right;">320,000</td>
          <td style="text-align:right;">81%</td>
          <td style="text-align:right;">63%</td>
          <td style="text-align:right;">80,000</td>
          <td>System rule change implemented</td>
        </tr>
        <tr>
          <td>Coding</td>
          <td style="text-align:right;">290,000</td>
          <td style="text-align:right;">45%</td>
          <td style="text-align:right;">52%</td>
          <td style="text-align:right;">95,000</td>
          <td>Audit cycle scheduled</td>
        </tr>
      </tbody>
    </table>
  </div>
</div>

Regulatory Reports

All regulatory references are UAE-specific and must comply with UAE PDPL, DOH, DHA, MOH, and HIE (NABIDH/Malaffi) requirements.

1. MOH / Federal-Level Reporting

While MOH does not typically require detailed denial reports, aggregated financial and utilization statistics may be requested for federal oversight.

  • RPT-DEN-MOH-001: Revenue Loss Due to Denials (Federal Summary)
  • Purpose: Provide MOH with high-level statistics on denied amounts and write-offs by facility and payer type (government vs private).
  • Content:
    • Total claims submitted, total denied amount, total recovered, total write-off
    • Breakdown by facility and payer type
  • Fields (examples):
    • facility_id, facility_name
    • period_start, period_end
    • total_claim_amount, total_denied_amount, total_recovered_amount, total_write_off_amount
  • Frequency: Annually or on request
  • Format: CSV or Excel; anonymized patient-level data (no Emirates ID, no PHI)

2. DOH (Abu Dhabi) – Shafafiya / eClaims

DOH focuses on claim and denial patterns for Abu Dhabi facilities.

  • RPT-DEN-DOH-001: DOH Denial Statistics Extract
  • Purpose: Support DOH analytics on denial patterns and payer performance.
  • Content:
    • Denial counts and amounts by DOH payer code, denial category, and specialty
    • Appeal rate and success rate by payer
  • Compliance:
    • Align with DOH eClaims / Shafafiya data dictionary
    • Use DOH payer and provider identifiers
  • Frequency: Monthly / Quarterly
  • Format: CSV/XML per DOH specification; no direct patient identifiers beyond those allowed in eClaims datasets.

DHA monitors claim and denial behaviour for Dubai-licensed facilities.

  • RPT-DEN-DHA-001: DHA Denial & Appeal Summary
  • Purpose: Provide DHA with aggregated denial and appeal statistics for eClaimLink claims.
  • Content:
    • Denial rate by DHA payer, category, and facility
    • Appeal rate and success rate
    • Average days to appeal and resolution
  • Compliance:
    • Use DHA payer codes and facility IDs
    • Conform to eClaimLink REST API payload structures for any automated submissions
  • Frequency: Monthly / Quarterly
  • Format: CSV/JSON as per DHA guidelines

4. NABIDH (Dubai) / Malaffi (Abu Dhabi) – HIE Quality Metrics

Denial data is not directly exchanged via HIE, but related quality and utilization metrics may be required.

  • RPT-DEN-HIE-001: Denial-Linked Quality Indicators
  • Purpose: Correlate denial categories (e.g., medical necessity, coding) with clinical documentation quality and HIE usage.
  • Content:
    • Denial rates for medical necessity vs completeness of clinical documentation (from EHR)
    • Denials related to missing NABIDH/Malaffi data (if tracked)
  • Frequency: Quarterly
  • Format: Aggregated CSV / dashboard

5. UAE PDPL – Data Protection & Audit

Under UAE PDPL (Federal Decree-Law No. 45/2021), the system must support:

  • RPT-DEN-PDPL-001: Denial Data Access Audit Log
  • Purpose: Demonstrate who accessed denial-related data (which may contain PHI) and when.
  • Content:
    • user_id, role, timestamp, action (view/export), denial_id or report ID
    • Source IP / device (if available)
  • Frequency: On-demand (for investigations) and quarterly summary

  • Format: PDF summary + CSV detail

  • RPT-DEN-PDPL-002: Data Subject Request Impact Report

  • Purpose: Identify denial records affected by a patient’s data access/rectification/erasure request.
  • Content:
    • List of denial and appeal records linked to the patient
    • Status of anonymization or restriction
  • Frequency: On-demand
  • Format: PDF / CSV; accessible only to DPO and authorized staff

All regulatory reports must:

  • Avoid unnecessary patient identifiers (minimization principle).
  • Use pseudonymization or aggregation where possible.
  • Log every export and transmission event in an audit trail.

Ad-Hoc Reporting

1. Available Data Fields for Custom Queries

The ad-hoc reporting layer should expose (read-only) a curated view over key tables:

From denial_analysis.denial_records

  • denial_id
  • claim_id
  • claim_line_id
  • patient_id (FK – masked or pseudonymized in self-service tools)
  • payer_id
  • facility_id
  • denial_date
  • denial_code
  • denial_description
  • denial_category_id
  • denied_amount
  • root_cause_id
  • is_preventable
  • assigned_analyst_id
  • status
  • resolution_date
  • resolution_type (e.g., overturned, partial, write_off, patient_billed)
  • recovered_amount

From denial_analysis.denial_categories

  • category_id
  • category_name
  • category_group (e.g., eligibility, authorization, coding)
  • responsible_department
  • is_active

From denial_analysis.denial_root_causes

  • root_cause_id
  • denial_id
  • root_cause_category
  • root_cause_detail
  • process_failure_point
  • responsible_department
  • identified_by
  • identified_date

From denial_analysis.appeals

  • appeal_id
  • denial_id
  • appeal_level
  • submission_date
  • submission_method (portal, eClaimLink, DOH eClaims, email)
  • submission_channel
  • supporting_docs (count or reference)
  • appeal_letter_path
  • follow_up_date
  • status
  • assigned_to

From denial_analysis.appeal_outcomes

  • outcome_id
  • appeal_id
  • response_date
  • payer_decision
  • recovered_amount
  • adjustment_code
  • notes
  • final_resolution

From denial_analysis.denial_trends

  • trend_id
  • period_start
  • period_end
  • payer_id
  • denial_category_id
  • denial_count
  • denied_amount
  • appeal_count
  • recovered_amount
  • prevention_actions_count

From denial_analysis.denial_prevention_actions

  • action_id
  • denial_category_id
  • payer_id
  • description
  • action_type
  • responsible_party
  • target_date
  • completion_date
  • status
  • pre_intervention_rate
  • post_intervention_rate
  • implementation_cost
  • reduction_in_denied_amount

From denial_analysis.payer_denial_scorecards

  • scorecard_id
  • payer_id
  • period_start
  • period_end
  • total_claims
  • total_denials
  • denial_rate
  • total_denied_amount
  • total_recovered
  • appeal_success_rate
  • avg_resolution_days
  • rank

Shared Entity References (read-only joins)

  • ehr-patient-mgmt.patients (limited fields: age band, gender, emirate – no Emirates ID in self-service)
  • ehr-patient-mgmt.facilities, departments
  • policy-contract-mgmt.payers
  • billing-claims.claims, claim_lines
  • ehr-patient-mgmt.users (for analyst names/roles)

All ad-hoc datasets must enforce row-level security based on user role and facility.

2. Export Formats

The reporting module must support:

  • CSV:
  • For data analysis in Excel/BI tools
  • UTF-8 encoding; comma-separated; header row
  • Excel (XLSX):
  • For finance and management users
  • Basic formatting and filters
  • PDF:
  • For official reports, sign-off, and sharing with regulators or payers
  • Includes headers/footers with facility name, period, and confidentiality notice
  • JSON (optional):
  • For integration with external analytics platforms

All exports must:

  • Be logged in an audit table (report_exports) with user_id, timestamp, report_id, filters, row_count.
  • Respect UAE PDPL by masking or excluding direct identifiers unless user has explicit permission.

3. Scheduled Report Delivery

The system should support scheduling for any standard or saved ad-hoc report:

  • Scheduling Options
  • Frequency: daily, weekly, monthly, quarterly, annually
  • Time of day (with facility timezone)
  • Start and end dates
  • Delivery Channels
  • Secure email with link to download (no PHI in email body)
  • Internal portal notification
  • SFTP drop for finance/analytics teams (if configured)
  • Security & PDPL
  • Access to scheduled report output requires authentication
  • Links expire after configurable period (e.g., 7 days)
  • For cross-entity reports (multiple facilities), only users with multi-facility roles can subscribe
  • Monitoring
  • Failed deliveries logged with error reason
  • Summary dashboard of scheduled jobs for BI/IT admins
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content/rcm/denial-analysis/07-kpis-reports.md Generated 2026-02-20 22:54