Charge Denial Rate (CDR) Calculator

The Remittance Advices (RAs) will reflect the decision made on the reviewed claim. Use the calculator to determine your Charge Denial Rate (CDR).

Total Dollars Reviewed: Determine what the Medicare reimbursement amount would have been for each claim if it were paid as billed.

Total Dollars Denied: is based on the ‘reviewed charges.’ For example, if a partial payment were allowed on the claim, the denied charges would equate to the difference between the amount that would have been paid if the claim had paid as billed and the amount that was actually paid.

To obtain the information needed to calculate the CDR, you will need to have your Remittance Advices (RAs), and access to the Direct Data Entry (DDE) system.

  • Full payment made: The payment amount will be on the RA when the processing of the claim is finalized.
  • Partial payment made: The RA will reflect the amount paid.
    • The amount denied can be viewed in the DDE system:
      • Claim page 4 will display the notes from the review and what was allowed and what was paid.
      • The total amount that would have been paid had the claim been paid as billed minus the actual payment amount equals the denied charges.
  • Denied Payment: The RA shows the reason code that coincides with the denial reason code, which may be viewed in the DDE system using the claims inquiry menu option.
    • Denied charges are calculated based on the difference between the amount that would have been paid had the claim been paid as billed and the amount that was actually paid.

Under Palmetto GBA’s review process, there are two different types of reviews:

  • Probe review:Predetermined number of claims that are selected for review. Probe reviews are usually initiated when data analysis or other reason indicates that there might be an issue with a specific provider or service. For probe reviews, the Charge Denial Rate (CDR) is calculated after the pre-determined number of claims have been selected and edit effectiveness performed.
  • Targeted Medical Review (TMR)/Corrective Action Plan (CAP): Reviews are initiated when a problem has already been identified, and more focused review is needed. For TMR/CAP reviews, the CDR is calculated when edit effectiveness is performed, at the end of each calendar quarter. This quarter is established when the TMR/CAP edit is initiated, and for provider-specific edits, the quarter is communicated to the provider in a notification letter, when the edit is established.
    Note: Both of these edit types/levels can be utilized for either provider-specific edits, which are looking at a specific provider(s), usually for an identified reason; or service-specific edits, which are looking at a specific service, across a state, region or other identified grouping.

Total Dollars Reviewed: Determine what the Medicare reimbursement amount would have been for each claim if it were paid as billed.

Total Dollars Denied: is based on the ‘reviewed charges.’ For example, if a partial payment were allowed on the claim, the denied charges would equate to the difference between the amount that would have been paid if the claim had paid as billed and the amount that was actually paid.

To obtain the information needed to calculate the CDR, you will need to have your Remittance Advices (RAs).

  • Full payment made: The payment amount will be on the RA when the processing of the claim is finalized.
  • Partial payment made: The RA will reflect the amount paid.
    • The total amount that would have been paid had the claim been paid as billed minus the actual payment amount equals the denied charges.
  • Denied Payment: The RA shows the reason code that coincides with the denial reason code.
    • Denied charges are calculated based on the difference between the amount that would have been paid had the claim been paid as billed and the amount that was actually paid.

Under Palmetto GBA’s review process, there are two different types of reviews:

  • Probe review: Predetermined number of claims that are selected for review. Probe reviews are usually initiated when data analysis or other reason indicates that there might be an issue with a specific provider or service. For probe reviews, the Charge Denial Rate (CDR) is calculated after the pre-determined number of claims have been selected and edit effectiveness performed.
  • Targeted Medical Review (TMR)/Corrective Action Plan (CAP): Reviews are initiated when a problem has already been identified, and more focused review is needed. For TMR/CAP reviews, the CDR is calculated when edit effectiveness is performed, at the end of each calendar quarter. This quarter is established when the TMR/CAP edit is initiated, and for provider-specific edits, the quarter is communicated to the provider in a notification letter, when the edit is established.
    Note: Both of these edit types/levels can be utilized for either provider-specific edits, which are looking at a specific provider(s), usually for an identified reason; or service-specific edits, which are looking at a specific service, across a state, region or other identified grouping.