Denial code 147 means that the provider's contracted or negotiated rate has either expired or is not on file. This indicates that the healthcare service provider and the insurance company or payer had previously agreed upon a specific rate for the services rendered, but either the agreed-upon rate has expired or the insurance company does not have a record of the negotiated rate. As a result, the claim is denied, and the provider may need to renegotiate the rate or provide documentation to support the agreed-upon rate.
Common causes of code 147 are:
1. Expired Provider Contract: One of the common causes of code 147 is when the provider's contracted rate with the payer has expired. This can happen when the provider fails to renew their contract within the specified timeframe.
2. Missing Contract Information: Another cause of code 147 is when the provider's negotiated rate is not on file with the payer. This can occur if there was an oversight or miscommunication during the contract negotiation process, leading to the payer not having the updated contract information.
3. Incorrect Contractual Terms: Sometimes, code 147 can be triggered if there are discrepancies or errors in the contractual terms between the provider and the payer. This could include incorrect reimbursement rates, coverage limitations, or other contractual obligations that are not aligned.
4. Inadequate Documentation: Insufficient documentation can also result in code 147. If the provider fails to provide the necessary documentation to support the negotiated rate or contract terms, the payer may deny the claim and assign this code.
5. Administrative Errors: Human errors during the billing and claims submission process can also lead to code 147. This could include mistakes in entering or updating the provider's contract information, resulting in the payer not recognizing the negotiated rate.
6. Lack of Communication: Poor communication between the provider and the payer can contribute to code 147 denials. If there is a breakdown in communication regarding contract renewals, updates, or changes, the payer may not have the accurate information needed to process the claim correctly.
7. Payer Policy Changes: Sometimes, code 147 denials can occur due to changes in the payer's policies or reimbursement guidelines. If the provider is not aware of these changes or fails to comply with the updated requirements, the claim may be denied with this code.
It is important for healthcare providers to address these common causes of code 147 to minimize denials and ensure timely reimbursement for their services.
Ways to mitigate code 147 include:
- Regularly review and update provider contracts: Ensure that all provider contracts are up to date and include negotiated rates. Regularly review the terms and conditions of these contracts to ensure that they are still valid and in effect.
- Maintain accurate and updated fee schedules: Keep fee schedules up to date with the latest negotiated rates for each provider. This will help ensure that the correct rates are being billed and minimize the chances of a denial due to expired or missing rate information.
- Implement a robust contract management system: Utilize a contract management system that can track and manage all provider contracts. This system should have alerts and reminders to notify you when contracts are about to expire, ensuring that you can take timely action to renew or renegotiate rates.
- Establish clear communication channels with payers: Maintain open lines of communication with payers to stay informed about any changes in contract terms or rates. Regularly engage with payers to verify that they have the most up-to-date provider contract information on file.
- Conduct regular audits and reviews: Perform regular audits of claims to identify any potential issues related to expired or missing provider contract rates. Conducting periodic reviews will help catch any discrepancies early on and allow for timely resolution.
- Train staff on contract management and billing processes: Provide comprehensive training to your billing and coding staff on contract management processes and procedures. Ensure they are aware of the importance of accurate and up-to-date provider contract information and how to properly bill claims based on negotiated rates.
By implementing these strategies, healthcare providers can minimize the risk of denials related to expired or missing provider contracted/negotiated rates.
The steps to address code 147, which indicates that the provider contracted/negotiated rate has expired or is not on file, are as follows:
- Review the contract: Start by reviewing the contract between your healthcare organization and the payer in question. Ensure that the contracted rates and terms are up to date and accurately reflected in your system.
- Contact the payer: Reach out to the payer's provider relations department to inquire about the status of the contracted rates. Verify if there have been any changes or updates that may have caused the expiration or omission of the negotiated rate.
- Provide supporting documentation: If you believe that the contracted rate is still valid and should be applied to the claim, gather any relevant documentation that supports your position. This may include copies of the contract, amendments, or any other communication that confirms the agreed-upon rate.
- Initiate a rate negotiation: If the contracted rate has indeed expired, or if there was an oversight in not having it on file, initiate a negotiation with the payer to establish a new agreement. Provide them with the necessary information to demonstrate the value and quality of your services, which may help in securing favorable rates.
- Appeal the denial: If you believe that the denial is incorrect or unjustified, follow the payer's appeal process. Prepare a well-documented appeal letter that outlines the reasons why the contracted rate should be applied and provide any supporting evidence.
- Monitor and track: Keep a record of all communication and actions taken regarding this denial code. Monitor the progress of your appeal or negotiation and follow up with the payer regularly to ensure that the issue is being addressed promptly.
By following these steps, you can effectively address denial code 147 and work towards resolving the issue with the provider contracted/negotiated rate.