Denial code 213

Denial code 213 is when a healthcare provider does not follow the rules about referring patients to other doctors or facilities, according to the law or the insurance company's policy.

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What is Denial Code 213

Denial code 213 is related to non-compliance with the physician self-referral prohibition legislation or payer policy. This means that the claim has been denied because it violates the rules and regulations set forth by the legislation or the specific policy of the payer. It indicates that the services or procedures provided may have been referred by a physician who has a financial interest in the entity providing the service, which is not allowed under the self-referral prohibition legislation or payer policy.

Common Causes of CARC 213

Common causes of code 213 are non-compliance with the physician self-referral prohibition legislation or payer policy.

Ways to Mitigate Denial Code 213

Ways to mitigate code 213 include:

  1. Educate physicians and staff: Ensure that all physicians and staff members are aware of the physician self-referral prohibition legislation and payer policies. Conduct regular training sessions to keep them updated on the regulations and guidelines.
  2. Implement compliance programs: Establish comprehensive compliance programs that include policies and procedures to prevent non-compliance with physician self-referral prohibition legislation. These programs should outline the steps to be taken to ensure adherence to the regulations.
  3. Conduct internal audits: Regularly review internal processes and documentation to identify any potential violations of the physician self-referral prohibition legislation. Conducting internal audits can help identify and rectify any non-compliance issues before they result in denials.
  4. Utilize technology solutions: Implement technology solutions such as electronic health record (EHR) systems and billing software that have built-in compliance checks. These systems can help flag any potential violations and ensure that claims are submitted correctly.
  5. Establish clear communication channels: Foster open communication channels between physicians, staff, and billing departments. Encourage them to report any concerns or potential violations they come across. This will help in identifying and addressing issues promptly.
  6. Stay updated with payer policies: Regularly review and stay updated with payer policies related to physician self-referral prohibition legislation. This will help ensure that claims are submitted in accordance with the specific requirements of each payer.
  7. Seek legal counsel: If there is any uncertainty or ambiguity regarding the physician self-referral prohibition legislation, seek legal counsel to ensure compliance. Legal professionals specializing in healthcare regulations can provide guidance and advice to prevent any potential violations.

By implementing these strategies, healthcare providers can mitigate code 213 and reduce the risk of denials related to non-compliance with physician self-referral prohibition legislation or payer policy.

How to Address Denial Code 213

The steps to address code 213, which indicates non-compliance with the physician self-referral prohibition legislation or payer policy, are as follows:

1. Review the specific legislation or policy: Take the time to thoroughly understand the legislation or policy that is being referenced in the denial code. This will help you identify any potential areas of non-compliance and determine the necessary actions to rectify the issue.

2. Conduct an internal audit: Perform an internal audit of your organization's practices to identify any instances of non-compliance with the legislation or policy. This may involve reviewing referral patterns, documentation, and any financial relationships that could potentially violate the self-referral prohibition.

3. Implement corrective measures: Once areas of non-compliance have been identified, take immediate action to rectify the situation. This may involve updating internal policies and procedures, providing additional training to staff members, or implementing new systems to ensure compliance moving forward.

4. Communicate with relevant stakeholders: If the denial code is related to payer policy, reach out to the payer to discuss the specific denial and seek clarification if needed. Engage in open communication to understand their expectations and work towards resolving the issue.

5. Monitor and track compliance: Establish a system to monitor and track compliance with the legislation or policy moving forward. This may involve regular audits, ongoing staff training, and the implementation of checks and balances to ensure adherence to the self-referral prohibition.

6. Seek expert guidance if necessary: If you are unsure about how to address the code or need assistance in ensuring compliance, consider seeking expert guidance. This could involve consulting with legal counsel or engaging with a healthcare revenue cycle management consultant who specializes in compliance matters.

By following these steps, healthcare providers can effectively address denial code 213 and work towards maintaining compliance with physician self-referral prohibition legislation or payer policies.

RARCs Associated to CARC 213

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