In the revenue cycle management of healthcare services, denial codes are used to indicate why a claim was denied or rejected by an insurance company or payer. Understanding these codes is crucial for managing and resolving denied claims efficiently. Here are some common denial codes and their typical meanings.
Patient Responsibility Denial Codes
PR-1: Deductible
Indicates that the patient is responsible for the deductible amount before the insurance company will cover any costs.
PR-2: Coinsurance
The amount that the patient is responsible for paying after the deductible has been met.
PR-3: Copayment
A fixed amount that the patient must pay for a covered healthcare service.
PR-4: Previous payment
The payer has already paid for the service, and no additional payment is due.
PR-5: Covered under a different plan
The service is covered under a different insurance plan that the patient may have.
PR-6: Non-covered service
The service provided is not covered under the patient’s current insurance plan.
PR-7: Not a covered benefit
Indicates that the benefit or service is not covered under the patient’s insurance policy.
PR-8: Adjustment reason not specified
The adjustment was made, but the specific reason for the adjustment is not clearly specified.
PR-9: Claim/service denied
A generic denial code indicating that the claim or service has been denied.
PR-22: Submission/billing error
There was an error in the claim submission or billing process that needs correction.
PR-23: Charges are not covered under the patient’s current plan
Charges were billed for a service that is not covered by the patient’s current plan.
Common Avoidable Denial Codes
CO-16: Claim/service lacks information or has submission/billing errors
- Explanation: The claim is missing necessary information or has billing errors that prevent processing.
- Avoidance Strategy: Ensure that claims are complete, with all required fields accurately filled out.
CO-22: This care may be covered by another payer per coordination of benefits
- Explanation: The patient may have more than one payer, and the claim was submitted to the wrong one.
- Avoidance Strategy: Verify the patient’s insurance information and the correct payer prior to submission.
CO-29: The time limit for filing has expired
- Explanation: The claim was not submitted within the time frame required by the payer.
- Avoidance Strategy: Monitor claim submission deadlines and ensure timely filing of claims.
CO-50: Non-covered services
- Explanation: The services provided are not covered under the patient’s insurance plan.
- Avoidance Strategy: Verify coverage for services during the eligibility check before rendering services.
CO-97: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
- Explanation: The procedure or service is bundled with another service that was already paid for.
- Avoidance Strategy: Understand payer-specific bundling rules to avoid submitting claims for services that are included in another procedure.
CO-109: Claim/service not covered by this payer/contractor. You must send the claim to the correct payer/contractor
- Explanation: The claim was submitted to the wrong payer.
- Avoidance Strategy: Confirm that the correct payer is billed and coordinate benefits where applicable.
CO-177: Patient has not met the required spend-down/deductible
- Explanation: The patient’s deductible has not been met, so the claim cannot be paid.
- Avoidance Strategy: Ensure the patient is informed of their deductible status and verify benefits before services are provided.
CO-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service
- Explanation: The provider was not credentialed or certified to perform the procedure on the date of service.
- Avoidance Strategy: Regularly verify provider credentials and ensure certification is valid for services being billed.
CO-18: Duplicate claim/service
- Explanation: The same claim was submitted more than once.
- Avoidance Strategy: Avoid duplicate submissions by using proper claim tracking and review processes.
CO-140: Patient/Insured health identification number and name do not match
- Explanation: The patient’s information does not match what is on file with the payer.
- Avoidance Strategy: Ensure accurate patient demographic and insurance information is entered during registration and billing.
Tips for Managing Denials
Review Denial Codes Carefully
Understand the specific code and reason for the denial to address the issue accurately.
Verify Information
Ensure all required information is correctly provided and verify against payer guidelines.
Appeal Denied Claims
If you believe the denial was incorrect, follow the payer’s appeal process to contest the decision.
Adjust Billing Practices
Identify trends in denials and adjust your billing practices or claim submissions accordingly.
Regular Training
Keep your billing and coding staff updated on payer policies and denial codes to minimize future denials.
Understanding and effectively managing denial codes can significantly improve your revenue cycle efficiency and reduce the number of denied claims.
