Denial management can be one of the most tedious processes as a healthcare organization. First, you receive the medical insurance denials. Second, you have to work those denials by submitting an appeal or correcting and resubmitting the claim. Obviously, this second step takes the longest amount of time to complete and many healthcare IT organizations offer products that solely focus on that step.
How do you determine if you should spend more time on the front-end or back-end?
What it means when we say denial reason codes have a high chance of prevention but a low overturn rate is that they that are preventable if the information can be gathered and confirmed up front or if information could be submitted with a claim when it processed if it was missing.
You do not want to be spending a lot of your resources towards fixing these high chance of prevention, low overturn rate denial reason codes on the back-end because front-end denials are more likely to be prevented through policy management and streamlining how your healthcare organization runs.
We’ve been helping medical practices, doctor’s offices, and hospitals manage their healthcare denials through our AppealsPlus product and we’ve noticed common denial codes that have a high chance of prevention. Below we’ve listed the 32 most common denial reason codes that have a high chance of prevention but a low overturn rate…
Most Common Denial Reason Codes
B8 - Alternative service available
B16 - New patient qual not met
B12 - Not documented in med record
N30 - Patient ineligible for this service
N198 - Rendering must be affiliated with pay-to
MA92 - No plan information or other insurance
M60 - Missing Certificate of Medical Necessity
M139 - Denied svcs exceed demo coverage
M119 - Need Valid National Drug Code (NDC)
53 - Provider related to patient
51 - Pre-existing condition
39 - Svc denied when authorization requested
38 - Network referral
31 - Patient not insured
29 - Exceeded timely filing
272 - Guidelines not met
27 - Expenses post coverage
26 - Expenses prior to coverage
242 - Not provided by network PCP
234 - Procedure not paid separately
231 - Mutually exclusive procedures
222 - Exceeds maximum hrs/days/units
22 - Other payer may cover per OCB
21 - Covered by no-fault carrier
20 - Covered by liability carrier
19 - Covered by Workers Comp
174 - Service prior to prescription
172 - Provider specialty adj
151 - Number services not supported
150 - Level of service not supported
15 - Authorization invalid/missing
138 - Appeal Proc/Time Limit
Not all Carc codes fully explain denials
These denial reason codes are a mixture of both CARC and RARC codes because not all CARC codes give a full explanation of a denial falls into. As a general example, CARC code 16 means “additional information”. The RARC code associated to with may place the denial in any one of 4 different categories. This means that you cannot look and sort on a CARC code alone. In some cases, you’ll need to dig down to what the RARC code was that cause the claim to be denied.
What are some common denial reason codes you experience?