Denial rate range by specialty (2026 data)
Industry-wide initial denial rate per Change Healthcare 2024 is 11.81%. By specialty: primary care 7-10%, internal medicine 8-11%, mental health 12-16%, behavioral health 13-18%, orthopedics 13-17%, OB-GYN 10-13%, radiology 9-12%, dermatology 8-11%, urgent care 9-12%, cardiology 11-14%, ABA therapy 14-19%. The driver categories differ: primary care denials are dominated by eligibility (CARC 27, 31), surgical specialties by prior auth (CARC 197), and behavioral health by medical necessity (CARC 50).
- Industry average: 11.81% (Change Healthcare 2024)
- Primary care: 7-10% (eligibility-driven)
- Behavioral health: 13-18% (medical necessity)
- Surgical specialties: 13-17% (prior auth)
Denial Rate by Specialty in 2026
By MedPrecision Editorial Team · Published
Denial rates vary widely by specialty, and the published industry average obscures meaningful differences. The Change Healthcare 2024 Revenue Cycle Denials Index reports an industry-wide initial denial rate of 11.81% — but that single number rolls together specialties with denial rates ranging from 6% to over 18%. Understanding the specialty-specific benchmark is what separates a practice that is performing in line with its peers from one that has a real operational gap.
Industry Baseline
Change Healthcare publishes an annual Revenue Cycle Denials Index based on adjudication data from its clearinghouse network. The 2024 edition reported an industry-wide initial denial rate of 11.81%, up from 10.15% in 2020. The index breaks denials into root cause categories: registration and eligibility (27% of all denials), missing or invalid data (16%), authorization (12%), medical necessity (11%), service not covered (8%), provider eligibility (5%), and the remainder distributed across coding, duplicates, and contractual issues. AHIP and AHA have published similar industry-level figures using different data sources, with results clustering in the 10-13% range. AAPC's 2023 workplace survey reports a similar mean across reporting respondents.
Primary Care, Internal Medicine, Family Practice
Primary care specialties run 7-10% initial denial rates, the lowest of any specialty band. The dominant denial categories are CARC 27 (coverage terminated) and CARC 31 (patient cannot be identified) — both eligibility issues that originate at scheduling or check-in. CARC 18 (duplicate claim) is the second cluster, often from billing the same E/M visit when a patient was seen for multiple issues that should have been combined under modifier 25. CARC 16 (missing information) also features when ICD-10 specificity is below LCD requirements. Practices with structured eligibility verification at scheduling typically operate at 7-8% denial rate; those without typically run 10-12%. The typical recovery rate on primary care denials is 65-75% on appeal.
Mental Health and Behavioral Health
Mental health and behavioral health specialties run 12-18% initial denial rates, among the highest of any outpatient specialty. The dominant denial category is CARC 50 (not medically necessary), driven by payer-specific session limits, frequency caps, and the lack of standardized medical necessity criteria across payers. CARC 197 (prior authorization required) is the second cluster, particularly for higher-level CPT codes (90837 for 60-minute psychotherapy) and for intensive outpatient programs. ABA therapy specifically reports denial rates at the upper end of the band (14-19%) because of the dual-track challenge of authorization and ongoing reauthorization for treatment plans. Behavioral health denials recover at lower rates (45-55%) because medical necessity disputes require detailed clinical documentation and many payers limit appeal levels.
Surgical Specialties (Orthopedics, General Surgery, ENT)
Surgical specialties run 13-17% initial denial rates. The dominant denial category is CARC 197 (prior authorization required), particularly for high-cost procedures like joint replacement, spinal fusion, and bariatric surgery. CARC 97 (procedure bundled) is the second cluster, driven by NCCI edit conflicts when a surgical claim includes multiple CPTs that should have been combined or modifier-59'd. CARC 50 (medical necessity) appears for elective procedures where the diagnosis ICD-10 does not meet payer LCD requirements. Days in A/R for surgical specialties runs 40-55 days because of the layered adjudication: hospital facility claim, surgical claim, anesthesia claim, and assistant surgeon claim all adjudicate on different timelines and any one can hold up payer-side processing.
OB-GYN, Pediatrics, and Women's Health
OB-GYN runs 10-13% initial denial rate, with global obstetric package billing accounting for a disproportionate share of complex denials. Global OB billing (CPT 59400, 59510, 59610, 59618) bundles antepartum, delivery, and postpartum care; partial-care scenarios (transfers, change of payer mid-pregnancy) require careful claim construction and frequently produce CARC 97 or CARC 16 denials. Pediatrics runs 8-11%, with EPSDT-specific Medicaid denials accounting for a notable share — well-child visits coded outside the state Medicaid EPSDT periodicity schedule, or missing the EP modifier where required, produce CARC 50 denials. Vaccine administration billing (CPT 90460/90461) has its own denial pattern when administration codes are not paired correctly with vaccine HCPCS codes.
Radiology, Cardiology, Imaging-Heavy Specialties
Radiology runs 9-12% initial denial rate; cardiology runs 11-14%. The dominant denial category for both is CARC 197 (prior authorization required) — payers including UnitedHealthcare, Aetna, and most BCBS plans require prior authorization for advanced imaging (CT, MRI, PET, nuclear medicine) and for stress tests, cardiac catheterization, and electrophysiology procedures. CARC 50 (medical necessity) is the second cluster, driven by Appropriate Use Criteria requirements for advanced imaging under Medicare. CARC 16 (missing information) appears when the ordering provider's NPI is missing or doesn't match the rendering site claim. Radiology denials specifically have a high prior-authorization-attached-to-wrong-CPT pattern — the PA was approved for the planned CPT but the actual procedure performed and billed differs.
DME, Home Health, and Documentation-Intensive Specialties
DME and home health typically run higher initial denial rates (often 15-20%) because of the documentation burden — face-to-face encounter requirements, signed orders, certificates of medical necessity, and detailed home health face-to-face documentation under 42 CFR 424.22. CARC 50 (medical necessity) is the largest single category, and the documentation gaps that drive it are usually upstream of the billing team — the ordering provider's documentation didn't include all the elements the LCD requires. Days in A/R routinely runs 50-70 days because of the multi-step documentation cycle and the recurring billing structure of monthly DME and per-episode home health claims.
What the Denominator Definition Changes
Reported denial rates differ depending on whether the denominator is total claims submitted, total claim lines submitted, or unique encounters. Change Healthcare's 11.81% is computed at the claim level. AAPC and MGMA sometimes report at the line level, which can be slightly higher because a claim with one denied line and four paid lines counts as one denial under claim-level methodology and 20% denial under line-level. When comparing your practice's reported denial rate against an industry benchmark, confirm both are claim-level measures. Also confirm whether 'denial' in the source includes clearinghouse rejections (which it should not — those are pre-adjudication failures) and whether it includes informational adjustments like CARC 45 (charge exceeds fee schedule) which are write-offs rather than recoverable denials.
Common Questions
Common questions about denial rate by specialty (2026): where the real numbers sit.
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Get a Free Billing Audit arrow_forwardWhat is the industry average denial rate in 2026?
Change Healthcare's 2024 Revenue Cycle Denials Index reports an industry-wide initial denial rate of 11.81%, up from 10.15% in 2020. The index draws on adjudication data from Change Healthcare's clearinghouse network and is the most-cited industry-wide source. AHIP, AHA, and AAPC have published similar figures from different data sources, generally clustering in the 10-13% range. The single industry number obscures meaningful specialty differences — primary care runs 7-10%, behavioral health 13-18%, surgical specialties 13-17%, DME and home health frequently above 15%. Always benchmark against the specialty-specific range, not the industry average. The trend across multiple data sources is denial rates rising 1-2 percentage points over the 2020-2024 window, driven primarily by tighter prior authorization requirements and more aggressive medical necessity adjudication.
Why do behavioral health denial rates run higher than primary care?
Behavioral health and mental health specialties report 12-18% initial denial rates compared to 7-10% for primary care. The gap traces to two structural factors. First, the dominant denial category in behavioral health is medical necessity (CARC 50), which is inherently more discretionary than the eligibility-driven denials that dominate primary care. Payers maintain session limits, frequency caps, and outcome-based criteria that vary by plan. Second, prior authorization requirements are heavier in behavioral health for higher-level CPT codes (90837 for 60-minute psychotherapy, 90791 for psychiatric diagnostic evaluation in some plans) and for intensive outpatient and partial hospitalization programs. ABA therapy sits at the upper end of the band (14-19%) because of the layered authorization structure for treatment plans plus ongoing reauthorization at 90 or 180-day intervals.
What is the top denial reason for surgical specialties?
For orthopedics, general surgery, ENT, and similar surgical specialties, CARC 197 (precertification absent) is the single largest denial category, representing 25-35% of all denials in most surgical practices. Payers including UnitedHealthcare, Aetna, Cigna, and most BCBS plans require prior authorization for elective surgical procedures, particularly joint replacement, spinal fusion, bariatric surgery, hysterectomy, and bunionectomy. The denial frequently occurs not because no PA was obtained but because the PA was obtained for a different CPT code than what was ultimately performed, or because the PA expired before the procedure was scheduled. CARC 97 (bundled procedure) is the second largest category, driven by NCCI edit conflicts when surgical claims include multiple procedures that should have been billed with modifier 59 or modifier XS for distinct anatomical structures.
Why are DME and home health denial rates higher than physician specialties?
DME and home health typically run 15-20% initial denial rates because the documentation burden is materially heavier than physician specialties. DME requires a signed physician order, a face-to-face encounter within specific timeframes (60 days before the order for many items, 6 months for power mobility under 42 CFR 410.38), a Certificate of Medical Necessity for certain item categories, and detailed delivery documentation. Home health requires the face-to-face encounter under 42 CFR 424.22 with documentation of the homebound status and the specific clinical findings supporting need for home health services. Most denials in these categories are CARC 50 (medical necessity) where the upstream documentation from the ordering provider didn't include all elements the LCD requires. The denials are often recoverable on appeal but require obtaining additional documentation from the referring physician — a multi-week cycle that drags days in A/R into the 50-70 day range.
Should I benchmark against industry average or specialty average?
Always benchmark against your specialty's range, not the industry-wide average. A primary care practice running an 11% denial rate is significantly underperforming its specialty benchmark of 7-10%, even though 11% is below the 11.81% industry average. A behavioral health practice running an 11% denial rate is performing well relative to its specialty range of 12-18%. Using the industry average leads to incorrect inferences in both directions. Within your specialty, also drill into the denial reason mix — your practice's top three CARC codes should resemble the specialty's typical pattern. If a primary care practice's top denial code is CARC 197 (prior auth), that points to a procedure mix or payer mix issue more than a generic billing problem; if a surgical practice's top code is CARC 27 (coverage terminated), front-end eligibility verification needs work.
What recovery rate should I expect on appealed denials?
Recovery rates on appealed denials vary by specialty and denial type. Eligibility-driven denials (CARC 27, 31) recover at 80-90% because the underlying issue is usually correctable — verify current coverage, resubmit. Prior authorization denials (CARC 197) recover at 50-70% on appeal — recovery depends on whether the service was authorizable retroactively and whether documentation supports the medical necessity case. Medical necessity denials (CARC 50) recover at 40-60% — the appeal requires detailed clinical documentation and many payers cap appeals at one or two levels. Bundling denials (CARC 97) recover at 50-65% when the appeal correctly applies modifier 59 or NCCI documentation. Across all categories, denials worked within 14 days recover at roughly twice the rate of denials worked after 60 days — appeal velocity is one of the most important operational levers for total recovery.
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