32 Common Denial Reason Codes with a High Chance of Prevention

32 Common Denial Codes with a High Chance of Prevention

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?