Denial code 170 is used when payment is denied for a service that was performed or billed by a provider who is not authorized to provide that specific type of service. To understand the reason for the denial, you can refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) in the payment remittance advice, if it is present.
Common causes of code 170 are:
- Incorrect provider type: The payment may be denied if the service or procedure was performed or billed by a provider who is not authorized or recognized to provide that specific service. This could be due to a mismatch between the provider's credentials and the service being billed.
- Lack of proper documentation: The denial may occur if the provider fails to submit the required documentation or supporting information along with the claim. This could include missing or incomplete medical records, referral letters, or other necessary documents to justify the service provided.
- Non-covered service: Code 170 may be triggered if the service or procedure is not covered under the patient's insurance plan. It is essential for providers to verify the patient's coverage and ensure that the services being provided are eligible for reimbursement.
- Out-of-network provider: If the provider is not contracted or enrolled as an in-network provider with the patient's insurance plan, the payment may be denied. It is crucial for providers to confirm their network status and inform patients about any potential out-of-network charges.
- Coding errors: Incorrect coding or billing errors can lead to code 170 denials. This could include using the wrong procedure code, modifier, or diagnosis code, resulting in the claim being rejected or denied.
- Lack of prior authorization: Some services require prior authorization from the insurance company before they can be performed. If the provider fails to obtain the necessary authorization, the payment may be denied.
- Exceeded benefit limits: Certain insurance plans have limitations on the number of times a specific service can be provided within a given time frame. If the service exceeds the allowed limit, the claim may be denied.
- Duplicate billing: Submitting multiple claims for the same service or procedure can result in denials. Providers should ensure that they are not billing for the same service more than once.
- Timely filing limits: Insurance companies have specific time frames within which claims must be submitted. If the claim is not filed within the designated time limit, it may be denied.
- Policy changes or updates: Denials can occur due to changes in insurance policies, coverage guidelines, or reimbursement rules. Providers should stay updated with the latest policy changes to avoid denials related to outdated or incorrect information.
It is important for healthcare providers to address these common causes of code 170 denials to improve their revenue cycle management and ensure timely and accurate reimbursement.
Ways to mitigate code 170 include:
- Provider Credentialing: Ensure that all providers are properly credentialed and authorized to perform the specific services they are billing for. This includes verifying their qualifications, licenses, and certifications.
- Clear Communication: Maintain open lines of communication with payers to understand their specific requirements for provider types. Regularly review and update your provider information with payers to avoid any discrepancies.
- Accurate Documentation: Ensure that all documentation, including medical records and claims, accurately reflects the provider type and the services rendered. This will help prevent any confusion or misinterpretation by payers.
- Staff Training: Provide comprehensive training to your billing and coding staff to ensure they are aware of the specific requirements for each provider type. This will help them accurately assign the correct codes and prevent any potential denials.
- Regular Audits: Conduct regular internal audits to identify any potential issues or discrepancies related to provider types. This will allow you to address any issues proactively and make necessary corrections before submitting claims.
- Stay Updated: Stay informed about any changes or updates in payer policies and guidelines related to provider types. Regularly review payer websites, newsletters, and other communication channels to ensure you are aware of any changes that may impact your billing processes.
- Utilize Technology: Implement advanced billing and coding software that can help identify any potential errors or discrepancies related to provider types. These tools can provide real-time alerts and suggestions to ensure accurate coding and billing.
By implementing these strategies, healthcare providers can minimize the risk of denials associated with code 170 and ensure a smoother revenue cycle management process.
The steps to address code 170 are as follows:
- Review the claim details: Carefully examine the claim to ensure that it was submitted correctly and that all necessary information is included. Check for any errors or omissions that may have triggered the denial.
- Verify provider type: Confirm that the provider type matches the services rendered and billed. If the code indicates that the payment was denied because it was performed or billed by the wrong type of provider, double-check the provider's credentials and qualifications.
- Check for coding errors: Review the coding used for the services provided. Ensure that the correct codes were used and that they accurately reflect the procedures performed. Look for any potential coding errors that may have led to the denial.
- Evaluate documentation: Assess the supporting documentation for the claim. Verify that it adequately justifies the services billed and demonstrates medical necessity. If the documentation is insufficient or incomplete, consider obtaining additional supporting documentation from the provider.
- Appeal if necessary: If you believe that the denial was incorrect or unjustified, consider filing an appeal. Compile all relevant information, including any supporting documentation, and follow the appropriate appeals process outlined by the payer. Provide a clear and concise explanation as to why the denial should be overturned.
- Educate providers: If denials related to provider type are recurring, consider providing education and training to ensure that providers understand the correct billing and coding practices. Offer guidance on how to avoid future denials related to provider type.
Remember, addressing denial codes requires a systematic approach that involves careful review, verification, and, if necessary, appealing the decision. By following these steps, healthcare providers can effectively address code 170 and work towards resolving the denial.