Pilot Validation
Pilot Denial Taxonomy
A structured classification of laboratory denial types, grouped by whether RequiSure could potentially address them before the lab performs a test. Provided by domain collaborators to focus the first pilot — not validated payer rules.
Collaborator-Supplied Pilot Taxonomy — Requires Validation. Denial categories were provided by laboratory-domain collaborators to help focus the first pilot. They are not validated payer rules and imply no RequiSure performance.
APre-Service / Potentially Preventable by RequiSure
Primary first-pilot opportunityPrimary first-pilot opportunity — identifiable before the lab performs the test.
Medical NecessityDocumentation SufficiencyClinical History / Evidence SufficiencyQuestionnaire / Required Information CompletenessCoding AlignmentPrior Authorization / ReferralEligibility / CoverageNon-Covered IndicationFrequency LimitationMissing Physician OrderSupporting-Documentation Completeness
BDownstream / Future RCM Scope
Not first-pilot scopeNot first-pilot scope. May later become analytics inputs, RCM feedback, or future capabilities.
Duplicate ClaimProvider/Lab EnrollmentBundling / Edit IssuesTimely FilingDownstream Claim Submission ProblemsPayer Processing Problems
CRequires Case-Specific Review
Case-by-caseMay be upstream or downstream depending on the facts.
Specimen-related problemsMixed documentation / claim issuesUnclear payer-denial categories
Collaborator Hypothesis
≈ 50%Collaborator Estimate — Requires Validation
Collaborator hypothesis that approximately 50% of current denials may involve issues potentially identifiable before or around the time of testing. This has not been validated.
This figure is explicitly NOT
RequiSure performanceachieved denial reductionvalidated baselineguaranteed preventabilityROImarketing claimcustomer outcome
Denial Preventability Classification (future, human-assigned)
Potentially Preventable Pre-Service
Issue existed before testing and RequiSure potentially could have identified it.
Not Preventable Pre-Service
Issue arose downstream or could not reasonably have been detected before testing.
Requires Review
Insufficient information to classify.
Collaborator-Supplied Denial Categories
12 categoriesMedical necessity
Diagnosis/ICD-10 does not sufficiently support why the test was orderedPatient history does not adequately demonstrate necessityClinical note does not sufficiently establish necessity
Documentation inadequacy
Incorrect/incomplete notesMissing historyMissing physician orderQuestionnaire lacks appropriate or sufficient questionsSupporting documentation insufficient
Coding mismatch
CPT/HCPCSICD-10ModifiersUnitsTest codeMismatched diagnosis/test combinations
Prior authorization / referral
Required authorization or referral is missing
Patient eligibility / coverage
Inactive coverageWrong payerService not covered
Non-covered indication
Test is not covered for the documented indication
Frequency limitation
Test performed more frequently than payer policy permits
Duplicate claim
Payer considers the same service already billed
Provider/laboratory enrollment
NPITaxonomyPTANPayer enrollment errors
Bundling / payer edits
Payer considers one service included in another billed service
Specimen/documentation problems
Insufficient documentationImproper specimen informationMissing order
Timely filing
Claim submitted after payer filing deadline