Denial code 198 means that the precertification, notification, authorization, or pre-treatment requirement has been exceeded. This indicates that the necessary approval or notification was not obtained before the treatment or service was provided, leading to the denial of the claim.
Common causes of code 198 are:
1. Failure to obtain preauthorization: One of the most common causes of code 198 is when healthcare providers fail to obtain the necessary preauthorization or precertification from the insurance company before providing a specific treatment or service. Insurance companies often require preauthorization to ensure the medical necessity and appropriateness of the treatment.
2. Lack of notification: Another common cause of code 198 is the failure to notify the insurance company in advance about certain treatments or services that require notification. Some insurance plans require providers to notify them within a specified timeframe before providing certain procedures or services.
3. Exceeding pre-treatment limits: Code 198 may also be triggered when the healthcare provider exceeds the pre-treatment limits set by the insurance company. These limits could include the number of visits, the duration of treatment, or the quantity of a specific medication.
4. Inadequate documentation: Insufficient or incomplete documentation can also lead to code 198 denials. If the healthcare provider fails to provide the necessary documentation to support the medical necessity of the treatment or service, the insurance company may deny the claim.
5. Incorrect coding: Sometimes, code 198 denials occur due to coding errors. If the healthcare provider submits incorrect or inaccurate codes related to preauthorization or notification, the claim may be denied.
6. Missed deadlines: Insurance companies often have specific deadlines for obtaining preauthorization or submitting notifications. If the healthcare provider fails to meet these deadlines, it can result in a code 198 denial.
7. Lack of medical necessity: Insurance companies may deny claims with code 198 if they determine that the treatment or service was not medically necessary. This could happen if the insurance company believes that a less expensive or alternative treatment would have been sufficient.
It is important for healthcare providers to address these common causes of code 198 denials to improve their revenue cycle management and ensure timely reimbursement for their services.
Ways to mitigate code 198 include:
- Implement a proactive pre-authorization process: Ensure that all necessary pre-certifications, notifications, authorizations, or pre-treatment requirements are obtained before providing services. This can be achieved by establishing a dedicated team or utilizing automated software to track and manage the pre-authorization process.
- Enhance communication with payers: Establish strong lines of communication with insurance payers to understand their specific pre-authorization requirements. Regularly review and update your knowledge of payer policies and guidelines to ensure compliance and avoid exceeding pre-treatment limits.
- Educate staff on pre-authorization requirements: Train your staff, including physicians, nurses, and administrative personnel, on the importance of obtaining pre-authorization for specific procedures or treatments. Provide them with clear guidelines and resources to facilitate the pre-authorization process.
- Utilize technology for real-time eligibility verification: Leverage technology solutions that offer real-time eligibility verification to confirm whether pre-authorization is required for a particular service. This can help prevent exceeding pre-treatment limits and reduce the risk of denials.
- Implement a robust documentation process: Ensure that all relevant documentation, including medical records, test results, and clinical notes, are accurately recorded and easily accessible. This will help support the need for pre-authorization and provide evidence in case of a denial.
- Conduct regular audits and reviews: Regularly review your billing and coding processes to identify any potential issues or patterns that may lead to exceeding pre-treatment limits. Conduct internal audits to ensure compliance with payer requirements and address any gaps or discrepancies promptly.
- Stay updated with industry changes: Keep abreast of changes in healthcare policies, regulations, and payer guidelines that may impact pre-authorization requirements. Stay connected with industry associations, attend conferences, and participate in webinars to stay informed and adapt your processes accordingly.
By implementing these strategies, healthcare providers can minimize the risk of exceeding pre-treatment limits and reduce the occurrence of denials associated with code 198.
The steps to address code 198, which indicates that precertification/notification/authorization/pre-treatment has been exceeded, are as follows:
- Review the patient's medical records and documentation to ensure that the necessary precertification/notification/authorization/pre-treatment was obtained prior to the service or treatment being provided.
- If the precertification/notification/authorization/pre-treatment was not obtained, determine the reason for the oversight. Was it due to a miscommunication, administrative error, or any other factor?
- Contact the insurance company or payer to discuss the situation and provide any additional information or documentation that may be required. Be prepared to explain the circumstances surrounding the lack of precertification/notification/authorization/pre-treatment and provide any supporting evidence, such as medical necessity or emergency situations.
- If the insurance company or payer denies the claim based on the lack of precertification/notification/authorization/pre-treatment, consider appealing the decision. Compile all relevant documentation, including medical records, physician notes, and any communication with the insurance company or payer, to support your appeal.
- Submit the appeal within the designated timeframe, following the specific guidelines and requirements outlined by the insurance company or payer. Ensure that all necessary forms and supporting documentation are included to strengthen your case.
- Monitor the progress of the appeal and follow up with the insurance company or payer regularly to ensure that it is being processed in a timely manner. Keep detailed records of all communication and any updates regarding the status of the appeal.
- If the appeal is successful, the claim will be reprocessed, and payment will be issued. If the appeal is denied, evaluate the next steps based on the specific circumstances and consult with the appropriate stakeholders, such as the billing department, healthcare providers, or legal counsel, if necessary.
Remember, it is crucial to address code 198 promptly and thoroughly to minimize any potential financial impact on your healthcare organization and ensure proper reimbursement for the services provided.