Denial code 184 is used when the prescribing or ordering provider is not eligible to prescribe or order the service that is being billed. This means that the provider who requested the service does not have the necessary qualifications or authorization to do so. To get more information about this denial code, you can refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if it is present in the claim.
Common causes of code 184 are:
- The prescribing/ordering provider does not have the necessary credentials or qualifications to prescribe/order the service that was billed.
- The provider's license or certification may have expired or been revoked, making them ineligible to prescribe/order the service.
- The provider may not be enrolled or registered with the appropriate regulatory bodies or insurance plans to prescribe/order the service.
- The service billed may require a specific specialty or expertise that the prescribing/ordering provider does not possess.
- The provider may have exceeded their scope of practice by prescribing/ordering the service.
- The service may require prior authorization or approval from the insurance company, and the provider failed to obtain it before billing.
- The provider may have made an error in entering their credentials or identification information when submitting the claim.
- The insurance company may have outdated or incorrect information regarding the provider's eligibility to prescribe/order the service.
- The service billed may not be covered or reimbursable under the provider's contract with the insurance company.
- The provider may have failed to meet certain documentation or medical necessity requirements for prescribing/ordering the service.
Ways to mitigate code 184 include:
- Ensure provider eligibility: Verify that the prescribing or ordering provider is eligible to prescribe or order the service being billed. This can be done by regularly checking the provider's credentials and ensuring they are licensed and authorized to perform the specific service.
- Maintain accurate provider information: Keep provider information up to date in your system, including any changes in their credentials or authorization status. Regularly review and update provider profiles to avoid any discrepancies that could lead to code 184 denials.
- Implement proper documentation processes: Ensure that all necessary documentation is in place to support the prescribing or ordering provider's eligibility. This includes maintaining records of their credentials, licenses, and any other relevant documentation required by payers.
- Educate providers on eligibility requirements: Communicate with providers about the specific eligibility criteria for prescribing or ordering services. Provide them with clear guidelines and instructions to follow to avoid any issues that could result in code 184 denials.
- Conduct regular audits: Perform routine audits of your billing and coding processes to identify any potential issues related to code 184 denials. This can help you identify patterns or trends that may indicate a need for further training or process improvements.
- Stay updated with payer policies: Stay informed about the latest payer policies and guidelines regarding provider eligibility. Regularly review and understand these policies to ensure compliance and minimize the risk of code 184 denials.
- Implement effective communication channels: Establish effective communication channels between billing staff, providers, and payers to address any questions or concerns related to provider eligibility. This can help resolve any issues promptly and prevent code 184 denials.
By implementing these strategies, healthcare providers can mitigate code 184 denials and improve their revenue cycle management processes.
The steps to address code 184 are as follows:
- Verify the eligibility of the prescribing/ordering provider: Check if the provider is authorized and eligible to prescribe/order the service that was billed. This can be done by reviewing the provider's credentials, licenses, and any applicable agreements or contracts.
- Identify any potential errors or discrepancies: Review the documentation and claims information to ensure that the correct provider information was submitted. Check for any inaccuracies or missing details that may have led to the code 184 denial.
- Contact the prescribing/ordering provider: Reach out to the provider mentioned in the claim to discuss the denial and gather any additional information or clarification that may be required. This communication can help identify any misunderstandings or resolve any issues related to the provider's eligibility.
- Update the provider's information if necessary: If it is determined that the provider's information needs to be updated or corrected, make the necessary changes in the system or database. This may involve updating the provider's credentials, licenses, or any other relevant information.
- Resubmit the claim with accurate information: Once the necessary updates have been made, resubmit the claim with the corrected provider information. Ensure that all the required documentation and supporting materials are included to avoid any further denials.
- Monitor the claim's status: Keep track of the resubmitted claim to ensure that it is processed correctly and that the code 184 denial is resolved. Follow up with the payer if needed to ensure timely reimbursement.
By following these steps, healthcare providers can effectively address code 184 denials and work towards resolving any issues related to the eligibility of the prescribing/ordering provider.