Denial code 117 is an indication that transportation expenses are only covered by the insurance provider up to the nearest facility that is capable of providing the required medical care.
Common causes of code 117 are:
1. Lack of medical necessity: The denial may occur if the transportation service is not deemed medically necessary by the payer. This could be due to the patient's condition not warranting transportation or if alternative means of transportation are available.
2. Inadequate documentation: Insufficient or incomplete documentation supporting the need for transportation can lead to a denial. This may include missing or incomplete medical records, lack of physician orders, or failure to provide supporting documentation such as the patient's inability to use public transportation.
3. Incorrect coding: If the transportation service is not coded correctly, it can result in a denial. This may involve using an incorrect procedure code or failing to include the necessary modifiers or diagnosis codes.
4. Out-of-network provider: If the transportation service is provided by a facility or provider that is not within the patient's insurance network, it may lead to a denial. Payers often have specific networks of approved providers, and using an out-of-network provider can result in non-coverage.
5. Prior authorization requirements: Some payers may require prior authorization for transportation services. If this authorization is not obtained before the service is rendered, it can result in a denial.
6. Billing errors: Errors in the billing process, such as incorrect patient information, incorrect insurance information, or missing required fields, can lead to denials. It is important to ensure accurate and complete billing information is submitted to avoid these denials.
7. Exceeding coverage limits: Payers may have specific coverage limits for transportation services, such as only covering transportation to the closest facility. If the service exceeds these limits, it may result in a denial.
8. Lack of supporting documentation from the referring provider: In some cases, the payer may require additional documentation from the referring provider to support the need for transportation. Failure to provide this documentation can result in a denial.
9. Timely filing limits: Payers often have specific timeframes within which claims must be submitted. If the claim is not filed within the designated timeframe, it may result in a denial.
10. Policy exclusions: Some payers may have specific policy exclusions for certain types of transportation services. If the service falls under one of these exclusions, it may result in a denial.
Ways to mitigate code 117 include:
- Verify network coverage: Before scheduling transportation for a patient, ensure that the facility being referred to is within the patient's insurance network. This can help prevent denials related to transportation coverage limitations.
- Document medical necessity: Clearly document the medical necessity for the patient to receive care at the chosen facility. Include detailed information about the required care that is not available at closer facilities. This documentation can support the claim and help prevent denials based on transportation limitations.
- Provide supporting documentation: Include any relevant supporting documentation, such as medical records, test results, or specialist referrals, that demonstrate the need for the patient to receive care at the chosen facility. This additional information can strengthen the claim and reduce the likelihood of denials related to transportation coverage.
- Communicate with payers: Establish open lines of communication with insurance payers to discuss cases where transportation to a specific facility is necessary. By proactively engaging with payers and providing them with the required information, you can increase the chances of obtaining approval for transportation coverage.
- Appeal denied claims: If a claim is denied due to code 117, consider appealing the decision. Provide additional evidence and documentation to support the medical necessity of the chosen facility. Be persistent in advocating for the patient's needs and ensure that all relevant information is included in the appeal.
- Educate staff and providers: Train your staff and providers on the importance of accurate documentation and the potential impact of code 117 denials. By ensuring that everyone involved in the revenue cycle management process understands the potential pitfalls, you can minimize the occurrence of denials related to transportation coverage limitations.
Remember, these strategies are general recommendations and may vary depending on the specific circumstances and payer policies. It is crucial to stay updated on the latest guidelines and requirements from insurance payers to effectively mitigate code 117 denials.
The steps to address code 117 are as follows:
- Review the patient's medical records and documentation to ensure that the transportation was necessary for the required care.
- Verify that the facility where the transportation was provided is indeed the closest one that can offer the necessary care.
- If there is any discrepancy or doubt, gather additional evidence such as medical reports, test results, or physician statements to support the need for transportation to the specific facility.
- Compile all the relevant information and prepare a well-documented appeal letter or response to the denial code.
- Clearly explain in the appeal letter why the transportation was necessary and why the closest facility was chosen.
- Provide any supporting documentation or evidence to strengthen the case.
- Submit the appeal letter and supporting documents to the appropriate department or contact the payer directly, following their specific guidelines for appeals.
- Keep track of the appeal process and follow up regularly to ensure that it is being reviewed and processed in a timely manner.
- If necessary, escalate the appeal to higher levels within the payer organization or involve a third-party intermediary to advocate on behalf of the healthcare provider.
- Continuously monitor the status of the appeal and be prepared to provide any additional information or clarification if requested by the payer.
By following these steps, healthcare providers can effectively address code 117 denials and increase the chances of overturning the decision.