Denial code 211 is used when National Drug Codes (NDC) are not eligible for rebates and therefore are not covered by the insurance provider.
Common causes of code 211 are:
1. Incorrect NDC: The National Drug Code (NDC) submitted on the claim may be incorrect or invalid. This could be due to a typographical error or using an outdated or discontinued NDC.
2. Non-covered Drug: The specific drug associated with the NDC is not covered by the patient's insurance plan. This could be due to the drug being classified as experimental, not approved by the FDA, or not included in the formulary of the insurance plan.
3. Lack of Rebate Eligibility: The NDC submitted does not meet the eligibility criteria for rebates. Certain drugs may be eligible for rebates based on agreements between pharmaceutical manufacturers and payers. If the submitted NDC does not qualify for rebates, it may result in a denial.
4. Missing or Incomplete Documentation: The claim may lack the necessary supporting documentation to justify the use of the specific NDC. This could include missing prescription details, medical necessity documentation, or prior authorization requirements.
5. Billing Errors: There may be errors in how the NDC is billed, such as incorrect units of measurement, incorrect dosage, or incorrect billing codes associated with the drug. These errors can lead to claim denials.
6. Coverage Limitations: The patient's insurance plan may have specific limitations or restrictions on coverage for certain drugs. This could include quantity limits, frequency limits, or restrictions based on the patient's diagnosis or medical condition.
7. Out-of-Network Provider: If the drug is prescribed or administered by an out-of-network provider, it may result in a denial. Insurance plans often have preferred networks or specific providers they cover, and using an out-of-network provider can lead to claim denials.
8. Prior Authorization Requirement: Some drugs require prior authorization from the insurance company before they can be covered. If the prior authorization process was not completed or the approval was not obtained, it can result in a denial.
9. Exceeded Maximum Allowable Quantity: The quantity of the drug billed may exceed the maximum allowable quantity set by the insurance plan. This could be due to prescribing or dispensing more than the allowed quantity within a specific timeframe.
10. Non-compliance with Formulary: The drug may not be included in the insurance plan's formulary, which is a list of medications covered by the plan. If the drug is not on the formulary, it may result in a denial unless an exception is granted.
It is important for healthcare providers to review and address these common causes to minimize claim denials and ensure timely reimbursement for services rendered.
Ways to mitigate code 211 include:
- Verify NDC eligibility: Before submitting a claim, ensure that the National Drug Code (NDC) is eligible for rebate and coverage. This can be done by cross-referencing the NDC with the payer's formulary or preferred drug list.
- Utilize appropriate modifiers: In some cases, using specific modifiers can help indicate the eligibility of a drug for rebate or coverage. Research and apply the appropriate modifiers as required by the payer to avoid denials related to NDC eligibility.
- Stay updated with payer policies: Regularly review and stay updated with the payer's policies regarding NDC eligibility. Payers may periodically update their formularies or preferred drug lists, so it is crucial to be aware of any changes that may affect reimbursement.
- Conduct thorough documentation: Accurate and detailed documentation is essential to support the medical necessity and eligibility of the drug. Ensure that all relevant information, such as the patient's diagnosis, treatment plan, and rationale for using the specific drug, is properly documented in the medical record.
- Communicate with prescribers: Collaborate closely with prescribers to ensure that the prescribed drugs align with the payer's coverage policies. If a drug is not eligible for rebate or coverage, work with the prescriber to explore alternative options that meet the patient's needs while complying with payer requirements.
- Implement pre-authorization processes: Consider implementing pre-authorization processes for drugs that are frequently associated with code 211 denials. This allows for prior review and approval from the payer, reducing the risk of denials related to NDC eligibility.
- Monitor claims and denials: Regularly monitor claims and denials to identify any patterns or trends related to code 211. Analyzing denial data can help identify areas for improvement and guide proactive measures to prevent future denials.
By implementing these strategies, healthcare providers can mitigate code 211 denials and improve the overall revenue cycle management process.
The steps to address code 211 are as follows:
1. Review the claim details: Carefully examine the claim to ensure that the National Drug Code (NDC) being billed is eligible for rebate. Cross-check the NDC against the list of covered drugs and medications provided by the payer.
2. Verify the rebate eligibility criteria: Familiarize yourself with the specific rebate eligibility criteria set by the payer. Ensure that the drug or medication being billed meets all the necessary requirements for rebate coverage.
3. Check for coding errors: Double-check the accuracy of the NDC code entered on the claim. Look for any potential errors or typos that might have occurred during data entry. Correct any mistakes and resubmit the claim if necessary.
4. Gather supporting documentation: Collect all relevant documentation that supports the eligibility of the drug or medication for rebate coverage. This may include invoices, purchase orders, or any other documentation that validates the use of the specific NDC code.
5. Communicate with the payer: Reach out to the payer's representative or the designated contact person to discuss the denial and provide the necessary documentation. Clearly explain why the drug or medication should be eligible for rebate coverage based on the provided documentation.
6. Appeal if necessary: If the payer continues to deny the claim despite providing supporting documentation, consider filing an appeal. Follow the payer's appeal process and provide any additional information or documentation that may strengthen your case.
7. Monitor and track progress: Keep a record of all communication and actions taken regarding the denial. Regularly follow up with the payer to track the progress of the appeal or any further steps required to address the denial.
Remember, each denial code may have specific steps to address it effectively. It is crucial to thoroughly understand the denial reason and work closely with the payer to resolve the issue promptly.