Denial code 274 is when a healthcare provider's fee/service is not payable due to a patient care coordination arrangement.
Denial code 274 is used when a fee or service is not payable due to the patient's Care Coordination arrangement. This means that the specific service or fee being claimed is not covered or reimbursable under the patient's Care Coordination agreement.
Common causes of code 274 are:
1. Lack of patient eligibility: The patient may not be eligible for the specific service or treatment due to their insurance coverage or care coordination arrangement. This could be due to the patient not meeting the necessary criteria or not having the required authorization.
2. Inadequate documentation: Insufficient or incomplete documentation of the patient's care coordination arrangement can lead to the denial of the claim. This may include missing or incorrect information regarding the patient's eligibility or the specific services covered under the arrangement.
3. Incorrect coding: Errors in coding, such as using the wrong procedure or diagnosis code, can result in the denial of the claim. It is essential to accurately assign the appropriate codes based on the patient's care coordination arrangement to ensure proper reimbursement.
4. Non-covered services: The specific service or treatment provided may not be covered under the patient's care coordination arrangement. It is crucial to verify the coverage and benefits of the patient's insurance plan before providing any services to avoid claim denials.
5. Lack of pre-authorization: Some care coordination arrangements require pre-authorization for certain services or treatments. If the necessary pre-authorization is not obtained before providing the service, the claim may be denied.
6. Exceeding coverage limits: The patient's care coordination arrangement may have limitations on the number of services or treatments covered within a specific time frame. If the services provided exceed these limits, the claim may be denied.
7. Billing errors: Mistakes in the billing process, such as incorrect patient information, missing or incorrect provider information, or errors in the submission of the claim, can lead to claim denials.
8. Timely filing limits: Failing to submit the claim within the specified time frame set by the insurance company can result in claim denials. It is important to adhere to the timely filing guidelines to avoid such denials.
9. Lack of medical necessity: If the service or treatment provided is not deemed medically necessary according to the patient's care coordination arrangement, the claim may be denied. It is crucial to ensure that the services rendered are justified and meet the necessary medical criteria.
10. Policy exclusions: Certain care coordination arrangements may have specific policy exclusions that restrict coverage for certain services or treatments. If the service falls under these exclusions, the claim may be denied.
Ways to mitigate code 274 include:
1. Ensure clear communication: To prevent this denial code, it is crucial to have open and transparent communication with patients regarding their care coordination arrangements. Clearly explain the limitations of their insurance coverage and any services that may not be payable under their specific arrangement.
2. Verify insurance coverage: Before providing any services, verify the patient's insurance coverage and eligibility. This will help identify any potential limitations or exclusions related to care coordination arrangements. By understanding the patient's coverage, you can proactively address any potential issues and avoid denials.
3. Obtain prior authorization: For services that may not be payable under a patient's care coordination arrangement, it is essential to obtain prior authorization from the insurance provider. This step ensures that the services are pre-approved and reduces the risk of denials.
4. Document thoroughly: Accurate and detailed documentation is crucial to prevent denials related to care coordination arrangements. Ensure that all relevant information, such as the patient's care plan, coordination efforts, and any necessary referrals, are properly documented. This documentation will serve as evidence of medical necessity and support the claim submission process.
5. Educate staff and providers: It is important to educate your staff and providers about the specific requirements and limitations of different care coordination arrangements. Regular training sessions and updates on insurance policies and guidelines will help them understand how to navigate potential pitfalls and avoid denials.
6. Monitor claims and denials: Implement a robust claims monitoring system to track and analyze denials related to care coordination arrangements. By identifying patterns or recurring issues, you can take proactive measures to address them and prevent future denials.
7. Stay updated with industry changes: Healthcare policies and regulations are constantly evolving. Stay informed about any changes that may impact care coordination arrangements and adjust your processes accordingly. This proactive approach will help you stay ahead of potential denials and ensure compliance with the latest guidelines.
By implementing these strategies, healthcare providers can mitigate denial code 274 and improve their revenue cycle management.
The steps to address code 274, "Fee/Service not payable per patient Care Coordination arrangement," are as follows:
1. Review the patient's Care Coordination arrangement: Carefully examine the patient's agreement or contract regarding Care Coordination. Ensure that the services being billed are not excluded or not covered under this arrangement.
2. Verify the documentation: Check if the documentation provided supports the services being billed. Ensure that the services are related to the patient's Care Coordination and are eligible for reimbursement.
3. Communicate with the Care Coordination team: Reach out to the Care Coordination team or department to discuss the denial. Seek clarification on why the service is not payable and gather any additional information or documentation that may be required.
4. Appeal the denial: If you believe that the denial is incorrect or unjustified, prepare an appeal. Provide all necessary documentation, including the patient's Care Coordination agreement, supporting medical records, and any other relevant information. Clearly explain why the service should be payable under the Care Coordination arrangement.
5. Follow up on the appeal: Monitor the progress of the appeal and ensure that it is being processed in a timely manner. Stay in touch with the relevant departments or individuals involved in the appeals process to provide any additional information or answer any questions they may have.
6. Evaluate the Care Coordination arrangement: If denials related to this code persist, it may be necessary to review and reassess the Care Coordination arrangement. Identify any gaps or issues that may be causing the denials and work towards resolving them to prevent future occurrences.
Remember, each denial code may have specific steps to address it effectively. It is crucial to thoroughly understand the denial reason and follow the appropriate procedures to resolve the issue.
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