Denial code 183 is used when the referring provider is not eligible to refer the service that has been billed. In order to understand the specific reason for the denial, it is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if it is present. This segment provides additional information and guidelines related to the denial code.
Common causes of code 183 are:
- The referring provider's credentials or eligibility to refer the specific service billed may have expired or been revoked.
- The referring provider may not be enrolled or registered with the appropriate insurance network or payer.
- The referring provider may not have the necessary specialty or qualifications to refer the service in question.
- The referring provider's National Provider Identifier (NPI) may be incorrect or invalid.
- The referring provider may not have obtained the required prior authorization or referral for the service.
- The referring provider's information may not have been accurately entered or updated in the healthcare provider's system.
- The referring provider may not be listed as an approved or participating provider with the specific insurance plan or payer.
- The referring provider's information may not match the information on file with the insurance plan or payer.
- The referring provider may have exceeded the allowed number of referrals for the specific service within a given time period.
- The referring provider's billing or coding practices may not comply with the guidelines or policies set by the insurance plan or payer.
Ways to mitigate code 183 include:
- Verify provider eligibility: Before referring a service, ensure that the referring provider is eligible to refer the specific service being billed. This can be done by checking the provider's credentials and ensuring they are authorized to refer the service in question.
- Maintain accurate provider records: Keep provider records up to date and ensure that any changes in provider eligibility or authorization are promptly updated. This will help prevent any discrepancies or errors in the referral process.
- Implement internal checks: Establish internal processes and checks to verify the referring provider's eligibility before submitting the claim. This can include cross-referencing the provider's credentials with the specific service being billed to ensure compliance.
- Educate referring providers: Provide ongoing education and training to referring providers regarding the eligibility criteria for referring specific services. This will help them understand the requirements and reduce the likelihood of incorrect referrals.
- Regularly review and update policies: Continuously review and update internal policies and procedures related to provider eligibility and referrals. This will ensure that any changes in regulations or requirements are promptly incorporated into the workflow.
- Conduct regular audits: Perform regular audits of referral processes to identify any potential issues or discrepancies. This will help identify and rectify any errors or non-compliance before claims are submitted.
- Utilize technology solutions: Implement technology solutions, such as automated referral management systems, that can help streamline the referral process and ensure compliance with eligibility requirements.
By following these strategies, healthcare providers can mitigate code 183 and reduce the likelihood of denials related to ineligible referring providers.
The steps to address code 183 are as follows:
- Verify the referring provider's eligibility: Check the referring provider's credentials and ensure they are eligible to refer the service billed. This can be done by reviewing their licensing, certifications, and any other relevant documentation.
- Contact the referring provider: Reach out to the referring provider to discuss the denial code and gather any additional information that may be needed. It is important to understand why the referring provider is not eligible to refer the service and address any potential issues or discrepancies.
- Review the documentation: Carefully review the documentation related to the referral. Ensure that all necessary information is included and that it meets the requirements set forth by the payer. If any missing or incomplete information is identified, work with the referring provider to obtain the necessary documentation.
- Update the system: Make any necessary updates to the system to reflect the correct referring provider information. This may involve updating the provider's credentials, contact details, or any other relevant data.
- Appeal if necessary: If you believe that the denial code is incorrect or unjustified, consider filing an appeal with the payer. Provide any supporting documentation or evidence that demonstrates the referring provider's eligibility to refer the service billed.
- Educate staff: Use the denial code as an opportunity to educate your staff on the importance of verifying referring provider eligibility before submitting claims. Implement processes and training to ensure that all referrals are properly vetted to avoid similar denials in the future.
By following these steps, you can effectively address code 183 and work towards resolving the issue with the referring provider's eligibility to refer the service billed.