Denial code 185 is used when the rendering provider (the healthcare professional who performed the service) is not eligible to perform the specific service that was billed. To understand the reason behind this denial code, you can refer to the 835 Healthcare Policy Identification Segment, specifically loop 2110 Service Payment Information REF, if it is present in the claim. This segment provides additional information about the policy or guideline that determines the eligibility of the rendering provider for the billed service.
Common causes of code 185 are:
- The rendering provider is not enrolled or registered with the payer to perform the specific service that was billed.
- The rendering provider's credentials or qualifications do not meet the payer's requirements for performing the service.
- The rendering provider's license or certification has expired or is not valid for the service billed.
- The rendering provider's National Provider Identifier (NPI) is not recognized or is inactive.
- The rendering provider's specialty or area of expertise does not match the service billed.
- The rendering provider's location or practice address does not match the service billed.
- The rendering provider is not listed as a participating provider with the payer for the specific service.
- The rendering provider's contract with the payer does not cover the service billed.
- The rendering provider's billing information, such as tax identification number or provider type, is incorrect or incomplete.
- The rendering provider's claim was submitted under the wrong provider number or group affiliation.
Please note that these are general causes and may vary depending on the specific payer's policies and guidelines. It is important for healthcare providers to review the specific denial code and consult the 835 Healthcare Policy Identification Segment for more detailed information and instructions.
Ways to mitigate code 185 include:
- Verify provider eligibility: Before submitting a claim, ensure that the rendering provider is eligible to perform the service being billed. This can be done by checking the provider's credentials, certifications, and any other relevant documentation.
- Conduct regular audits: Implement a system of regular audits to review the eligibility of rendering providers. This can help identify any potential issues or discrepancies before claims are submitted, reducing the likelihood of receiving code 185 denials.
- Improve documentation accuracy: Accurate and detailed documentation is crucial in preventing code 185 denials. Encourage providers to document all relevant information, including their eligibility to perform the billed service. This will provide supporting evidence in case of any disputes or audits.
- Enhance communication with payers: Establish open lines of communication with payers to clarify any questions or concerns regarding provider eligibility. Proactively address any issues or discrepancies to prevent denials related to code 185.
- Stay updated with payer policies: Regularly review and stay updated with payer policies and guidelines regarding provider eligibility. This will help ensure compliance and reduce the risk of receiving code 185 denials.
- Train staff on eligibility requirements: Provide comprehensive training to your staff, including billing and coding personnel, on the specific eligibility requirements for rendering providers. This will help them accurately identify and address any potential issues that could lead to code 185 denials.
- Implement technology solutions: Leverage technology solutions such as revenue cycle management software or electronic health record systems that have built-in checks and alerts for provider eligibility. These tools can help identify any potential issues before claims are submitted, reducing the likelihood of denials related to code 185.
By implementing these strategies, healthcare providers can mitigate code 185 denials and improve their revenue cycle management processes.
The steps to address code 185 are as follows:
- Verify the eligibility of the rendering provider: Check the provider's credentials and ensure that they are eligible to perform the service that was billed. This can be done by reviewing the provider's qualifications, certifications, and any other relevant documentation.
- Review the service billed: Cross-reference the service that was billed with the rendering provider's scope of practice. Ensure that the service falls within their authorized capabilities. If there is any discrepancy, investigate further to determine if there was an error in coding or if the service was indeed outside the provider's scope.
- Communicate with the rendering provider: Reach out to the rendering provider to discuss the denial code and gather any additional information that may be needed. This could include clarification on the service performed, any supporting documentation, or any other relevant details that can help address the denial.
- Determine if an appeal is necessary: Evaluate whether the denial is valid or if there are grounds for an appeal. If it is determined that the rendering provider is indeed eligible to perform the service billed, gather all necessary documentation to support the appeal process. This may include the provider's credentials, relevant policies, and any other supporting evidence.
- Submit a well-documented appeal: Prepare a comprehensive appeal letter that clearly outlines the reasons why the denial is incorrect. Include all relevant documentation and supporting evidence to strengthen the appeal. Ensure that the appeal is submitted within the designated timeframe and to the appropriate entity, as specified by the payer.
- Follow up on the appeal: Monitor the progress of the appeal and follow up with the payer to ensure that it is being processed. Keep track of any communication or correspondence related to the appeal and be prepared to provide any additional information that may be requested.
By following these steps, healthcare providers can effectively address denial code 185 and work towards resolving the issue in a timely manner.