Denial code 128 is indicating that the services provided for a newborn are already covered under the mother's insurance plan. This means that separate billing for the newborn's services is not necessary as they are included in the mother's coverage.
Common causes of code 128 are:
1. Incorrect patient information: The denial code 128 may occur if the patient's information, such as the date of birth or relationship to the insured, is entered incorrectly. This can lead to the claim being denied as the system may not recognize the newborn as being covered under the mother's insurance.
2. Missing or incomplete documentation: If the necessary documentation, such as the birth certificate or proof of relationship, is not provided or is incomplete, the claim may be denied with code 128. It is essential to ensure that all required documents are submitted accurately and in a timely manner to avoid this denial.
3. Timing issues: The timing of submitting the claim can also be a common cause of code 128 denials. If the claim for the newborn's services is submitted separately from the mother's claim or if there is a delay in submitting the claim, it may result in a denial with this code. It is crucial to follow the specific guidelines and timelines set by the insurance company for submitting claims related to newborn services.
4. Incorrect coding: Another common cause of code 128 denials is incorrect coding. If the services provided to the newborn are not coded correctly or if there is a mismatch between the codes used for the mother and the newborn, the claim may be denied. It is important to ensure accurate coding and to use the appropriate codes for both the mother and the newborn.
5. Insurance coverage limitations: Some insurance plans have specific limitations or restrictions on coverage for newborn services. If the services provided exceed the coverage limits or are not eligible for reimbursement under the insurance plan, the claim may be denied with code 128. It is essential to verify the insurance coverage details and understand any limitations or exclusions related to newborn services.
6. Coordination of benefits issues: If there are coordination of benefits (COB) discrepancies between the mother's and the newborn's insurance plans, it can lead to denials with code 128. It is crucial to ensure that the COB information is accurately provided and that any coordination requirements are met to avoid claim denials.
Please note that these are general common causes of code 128 denials and may vary depending on the specific circumstances and insurance policies. It is recommended to review the denial details and work closely with the billing and coding team to address and resolve any specific denial issues.
Ways to mitigate code 128 include:
- Verify eligibility: Before providing services to a newborn, it is crucial to verify the eligibility of both the mother and the newborn. Ensure that the newborn is covered under the mother's insurance plan and that the coverage includes newborn services.
- Submit accurate documentation: When submitting claims for newborn services, make sure to include all necessary documentation, such as the mother's insurance information, the newborn's date of birth, and any other relevant details. Accurate and complete documentation can help prevent denials related to code 128.
- Coordinate with the insurance company: In cases where the newborn's services are covered under the mother's allowance, it may be necessary to coordinate with the insurance company to ensure proper billing and reimbursement. Contact the insurance company to understand their specific requirements and procedures for billing newborn services.
- Educate staff and providers: Ensure that your staff and healthcare providers are aware of the guidelines and policies related to code 128. Provide training and education on how to properly document and bill for newborn services to minimize the risk of denials.
- Conduct regular audits: Regularly review your billing processes and claims to identify any potential issues or errors related to code 128. Conducting audits can help identify areas for improvement and ensure compliance with insurance policies.
By implementing these strategies, healthcare providers can reduce the likelihood of denials associated with code 128 and improve their revenue cycle management.
The steps to address code 128 are as follows:
- Review the patient's insurance policy: Verify if the newborn's services are indeed covered under the mother's allowance. Check the specific terms and conditions of the policy to ensure accuracy.
- Confirm accurate patient information: Double-check that the patient's information, including the mother's insurance details, is correctly entered into the billing system. Any errors in data entry can lead to claim denials.
- Verify the billing codes: Ensure that the correct billing codes are used for the newborn's services. Review the documentation and compare it with the codes submitted on the claim. Any discrepancies may result in a denial.
- Provide supporting documentation: If the insurance company requires additional documentation to support the claim, gather and submit it promptly. This may include the mother's medical records, proof of the newborn's relationship to the insured, or any other relevant documents.
- Appeal the denial if necessary: If the claim is denied despite following the above steps, consider filing an appeal. Review the denial letter for instructions on how to appeal and provide any additional information or documentation required to support the claim.
- Follow up with the insurance company: Keep track of the claim's progress and follow up with the insurance company regularly. This will help ensure that any issues or discrepancies are addressed promptly and that the claim is processed correctly.
By following these steps, healthcare providers can effectively address code 128 and work towards resolving any denials related to newborn services covered under the mother's allowance.