Claims Denial Cost Calculator
Estimate how much revenue your organization loses to preventable claim denials — and how much you could recover with real-time claims validation.
Your Claims Profile
Total claims submitted per year
Mean reimbursement per claim
Industry average: 5-15%
Denial Reason Mix
Code-Level Analysis(Optional)
Enter your top billed CPT/HCPCS codes to get specific NCCI edit, MUE limit, and payment data from CMS.
Total Annual Revenue
$7,500,000
50,000 claims at $150 avg
Revenue Lost to Denials
$750,000
5,000 denied claims (10%)
Preventable Denial Loss
$503,625
Addressable with pre-submission validation
Estimated Recoverable
$302,175
Conservative 60% recovery rate
Denial Breakdown by Reason
| Code | Reason | Denied | Preventable | $ Recoverable |
|---|---|---|---|---|
| CO-4 | Coding Error | 750 | 638 | $57,375 |
| CO-11 | Not Covered | 1,000 | 700 | $63,000 |
| CO-97 | Already Adjudicated | 600 | 570 | $51,300 |
| OA-23 | Not Authorized | 400 | 160 | $14,400 |
| CO-16 | Missing Information | 900 | 720 | $64,800 |
| CO-151 | MUE Exceeded | 600 | 570 | $51,300 |
How FHIRfly Prevents Denials
Most claim denials are preventable with the right data at the right time. FHIRfly provides four API endpoints that catch common denial reasons before claims leave your billing system — turning reactive rework into proactive validation.
NCCI PTP Validation
Query the CMS National Correct Coding Initiative procedure-to-procedure edits in real time. Before submitting a claim with multiple CPT codes, check whether code pairs are allowed together, require a modifier, or are mutually exclusive. This catches the most common coding denials — CO-4 (coding error) and CO-97 (already adjudicated) — before they reach the payer.
GET /v1/ncci/validate
MUE Limits
Medically Unlikely Edits set the maximum units of service a provider would report for a single patient on a single day. FHIRfly returns the current MUE value and rationale for any CPT/HCPCS code, so your billing system can flag over-coded claims before submission. MUE violations (CO-151) are one of the easiest denials to prevent.
GET /v1/mue/:hcpcs
PFS/RVU Data
Access the Medicare Physician Fee Schedule with work, practice expense, and malpractice RVU components. Use accurate payment rates to forecast expected reimbursement, identify undercoded services, and ensure claims include all required supporting data. Reduces CO-16 (missing information) denials by validating claims are complete before submission.
GET /v1/pfs/:hcpcs
Coverage Check
Verify that an ICD-10 diagnosis code supports the billed CPT procedure according to Medicare Local and National Coverage Determinations (LCD/NCD). Coverage mismatches — where the diagnosis doesn't justify the procedure — are the single largest category of denials (CO-11). Pre-submission coverage validation eliminates these before they cost you.
GET /v1/coverage/check
AI Agent Integration via MCP Server
Your AI coding assistant (Claude, GPT, etc.) can query all of these APIs in real-time via FHIRfly's MCP server — automatically evaluating every claim before submission. No manual lookups needed.
Learn about MCP integration