In the world of medical billing, denials are an inevitable part of the process. Understanding denial codes is crucial to the success of healthcare revenue cycles. In this blog post, we’ll provide a comprehensive list of denial codes to help you navigate the complexities of medical billing and coding.
Why Do Denials Happen?
Denials can occur for various reasons, such as incomplete or inaccurate claim submissions, eligibility issues, coding errors, or lack of medical necessity. These codes provide insight into why a claim was rejected.
Common Denial Codes
- CO-22 – This Care May Be Covered By Another Payer: Indicates that the primary insurer has denied the claim because it should be covered by a secondary insurance provider.
- PR-96 – Non-Covered Charge(s): Denotes that the specific service provided is not covered by the patient’s insurance plan.
- CO-97 – The Benefit for this Service is Included in the Payment or Allowance for another Service or Procedure Under the Plan: Suggests that the service billed is bundled with another service or procedure, and separate payment is not allowed.
- PR-204 – This Service/Equipment/Drug is Not Covered under the Patient’s Current Benefit Plan: Informs that the patient’s insurance plan does not cover the service, equipment, or drug.
- CO-45 – Charges Exceed the Maximum Allowed or Contracted Rate: Denotes that the billed charges exceed the maximum allowed or contracted rate for the service.
- PR-197 – Precertification/Authorization/Notification Missing: Indicates that the provider failed to obtain the necessary preauthorization or notification for the service.
- CO-15 – Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider: Suggests that the authorization number provided does not match the billed services or provider.
- PR-109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor: Instructs that the claim was sent to the wrong payer or contractor, and it must be resubmitted to the correct entity.
- CO-23 – The impact of prior payer(s) adjudication, including payments and/or adjustments: Explains that the claim has already been processed by another payer, and adjustments have been made accordingly.
- PR-165 – This procedure is not covered when performed in this place of service: States that the procedure is not covered when performed in the specific place of service.
- CO-24 – Charges are covered under a capitation agreement/managed care plan: Implies that the billed charges are covered under a capitation agreement or a managed care plan.
- PR-2 – Coinsurance Amount: Informs that the patient is responsible for a coinsurance amount, and it must be collected.
Navigating Denial Codes
While the list above includes some common denial codes, there are many more that can vary depending on the payer and the specific situation. Properly understanding these codes is essential for healthcare providers, billers, and coders to address and resubmit claims accurately.
Maximizing Reimbursements
Efficiently addressing denials and resubmitting claims is vital to maximizing reimbursements and ensuring the financial health of healthcare organizations.
Your Path to Success
As you embark on a career in medical billing and coding or work within the healthcare industry, understanding denial codes is a valuable skill. It’s not just about decoding numbers; it’s about ensuring a smooth and efficient revenue cycle for healthcare providers and, ultimately, better patient care.
Resubmission Strategies
Learning how to work with denial codes is an integral part of the healthcare revenue cycle. Your role in addressing and resubmitting claims is vital for the financial stability of healthcare organizations, ensuring they can continue to provide quality care to patients.
