Denial code 166 means that the services for which the claim was submitted were done after the payer's responsibility for processing claims under the specific plan had ended. In other words, the claim was filed too late and the payer is denying it because it falls outside the timeframe for claim submission.
Common causes of code 166 are:
- Late submission: The services were submitted to the payer after the specified timeframe for claim submission had expired. Payers typically have specific deadlines for claim submission, and if the provider fails to submit the claim within the given timeframe, it may result in a denial with code 166.
- Termination of coverage: The payer's responsibility for processing claims under the patient's insurance plan had ended before the services were submitted. This could occur if the patient's coverage was terminated or if they switched to a different insurance plan.
- Inactive policy: The patient's insurance policy was no longer active at the time the services were provided. This could happen if the patient failed to renew their policy or if there were issues with the insurance company's records.
- Incorrect billing period: The services were billed for a period of time that fell outside the payer's coverage dates. This could occur if the provider mistakenly billed for services that were provided before or after the patient's insurance coverage was in effect.
- Failure to obtain pre-authorization: Certain services may require pre-authorization from the insurance company before they can be billed. If the provider did not obtain the necessary pre-authorization, the claim may be denied with code 166.
- Non-covered services: The services provided were not covered under the patient's insurance plan. This could be due to policy exclusions or limitations that were not properly identified or communicated to the provider.
- Coordination of benefits (COB) issues: If the patient has multiple insurance policies, there may be coordination of benefits issues that need to be resolved. If the provider did not correctly identify the primary payer or failed to follow the COB guidelines, it could result in a denial with code 166.
It is important for healthcare providers to review the specific denial code and corresponding explanation to determine the exact cause and take appropriate actions to address the denial and resubmit the claim if necessary.
Ways to mitigate code 166 include:
- Timely submission: Ensure that claims are submitted within the specified timeframe as per the payer's guidelines. Implement efficient processes to track and submit claims promptly, reducing the chances of submitting claims after the payer's responsibility for processing claims has ended.
- Clear communication: Maintain open lines of communication with payers to stay informed about any changes in their claim processing timelines. Regularly check for updates on payer websites or through electronic communication channels to ensure that claims are submitted before the deadline.
- Automated reminders: Utilize technology solutions that offer automated reminders for claim submission deadlines. Implementing a robust revenue cycle management system can help in setting up alerts and notifications to ensure timely claim submissions.
- Streamlined workflows: Optimize internal processes to minimize delays in claim submission. Implement efficient workflows that prioritize claim processing and ensure that claims are submitted as soon as they are ready for submission.
- Regular training and education: Provide ongoing training and education to staff members involved in the revenue cycle management process. Keep them updated on payer policies and guidelines to ensure they are aware of any changes in claim submission deadlines.
- Real-time eligibility verification: Verify patient eligibility and coverage details in real-time before providing services. This helps in identifying any potential issues with the payer's responsibility for processing claims under the plan and allows for timely adjustments in the claim submission process.
- Robust documentation: Maintain accurate and complete documentation of all services provided. This includes documenting the date of service, the patient's insurance information, and any other relevant details. Having comprehensive documentation can help in resolving any disputes regarding the submission timeline.
By implementing these strategies, healthcare providers can reduce the likelihood of encountering code 166 and improve their revenue cycle management processes.
The steps to address code 166 are as follows:
- Review the submission date: Verify the date when the claim was submitted to determine if it was indeed submitted after the payer's responsibility for processing claims under the plan ended. This can help identify any potential errors in the submission timeline.
- Check the payer's contract: Review the contract or agreement with the payer to understand the specific terms and conditions regarding claim submission deadlines. Ensure that the claim was submitted within the designated timeframe.
- Verify the payer's responsibility end date: Confirm the date when the payer's responsibility for processing claims under the plan ended. This information can usually be found in the payer's policy documents or by contacting their customer service department.
- Identify any exceptions or extensions: Determine if there are any exceptions or extensions to the claim submission deadline. Some payers may allow for certain circumstances where claims can be submitted after the responsibility end date. Check for any applicable guidelines or policies that may apply.
- Appeal or resubmit the claim: If it is determined that the claim was indeed submitted after the payer's responsibility end date and no exceptions or extensions apply, consider appealing the denial or resubmitting the claim if allowed. Provide any necessary documentation or justification to support the appeal or resubmission.
- Track and monitor future claim submissions: Implement processes to ensure that claims are submitted within the designated timeframe in the future. This may involve setting up reminders or utilizing technology solutions that can help track submission deadlines.
By following these steps, healthcare providers can effectively address code 166 and take appropriate actions to resolve the denial or resubmit the claim within the payer's guidelines.