DENIAL CODES

Denial code P12

Denial code P12 is a fee schedule adjustment related to workers' compensation claims. The payer and provider need to refer to specific segments in the 835 electronic remittance advice for more information. This code is applicable only for workers' compensation cases.

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What is Denial Code P12

Denial code P12 is related to a workers' compensation jurisdictional fee schedule adjustment. This means that the payer has made an adjustment to the claim or line level based on the fee schedule specific to workers' compensation cases. If the adjustment is at the claim level, the payer is required to send additional information in the form of the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Providers should refer to this segment for more details.

If the adjustment is at the line level, the payer must send information in the 835 Healthcare Policy Identification Segment (Loop 2110 Service Payment Information REF) if the regulations apply. Providers should refer to this segment for more specific information regarding the adjustment.

It's important to note that this denial code is applicable only to workers' compensation cases and should be used exclusively for such cases.

Common Causes of CARC P12

Common causes of code P12 are:

1. Incorrect submission of workers' compensation jurisdictional fee schedule adjustment: This code may be triggered if the adjustment is not submitted correctly according to the specific guidelines set by the workers' compensation jurisdiction. It is important for providers to ensure that they follow the correct procedures and submit the adjustment accurately.

2. Missing or incorrect information in the 835 Class of Contract Code Identification Segment: If the adjustment is at the claim level, the payer must send the necessary information in the 835 Class of Contract Code Identification Segment. If this segment is missing or contains incorrect information, it can result in the P12 code.

3. Missing or incorrect information in the 835 Healthcare Policy Identification Segment: If the adjustment is at the line level, the payer must send the required information in the 835 Healthcare Policy Identification Segment. If this segment is missing or contains inaccurate information, it can lead to the P12 code.

4. Failure to comply with workers' compensation regulations: This code is specific to workers' compensation claims, and it may be triggered if the provider fails to comply with the regulations set by the workers' compensation jurisdiction. It is crucial for providers to stay updated with the latest regulations and ensure that their submissions align with the requirements.

5. Non-compliance with workers' compensation fee schedule: The P12 code may be caused by non-compliance with the workers' compensation fee schedule. Providers need to ensure that they are using the correct fee schedule and applying the appropriate adjustments according to the guidelines provided by the jurisdiction.

It is important for healthcare providers to review their claims and ensure that they are submitting accurate and compliant information to avoid denials with the P12 code. By addressing these common causes, providers can improve their revenue cycle management and minimize claim denials.

Ways to Mitigate Denial Code P12

Ways to mitigate code P12 include:

1. Ensure accurate and complete documentation: To prevent this code, healthcare providers should ensure that all documentation related to workers' compensation claims is accurate and complete. This includes capturing all relevant information such as the nature of the injury, treatment provided, and any other necessary details.

2. Verify workers' compensation jurisdictional fee schedules: Providers should regularly verify the fee schedules specific to workers' compensation in their jurisdiction. By staying up-to-date with the latest fee schedules, providers can ensure that they are billing accurately and in accordance with the regulations.

3. Implement robust claims management systems: Investing in a comprehensive claims management system can help providers identify and address potential issues before they result in denials. These systems can flag any discrepancies or missing information in claims related to workers' compensation, allowing providers to rectify them promptly.

4. Conduct regular internal audits: Regular internal audits can help identify any potential coding errors or inconsistencies in the billing process. By conducting these audits, providers can proactively address any issues and ensure compliance with workers' compensation regulations.

5. Stay informed about regulatory changes: It is crucial for providers to stay updated on any changes in workers' compensation regulations that may impact billing and reimbursement. This can be achieved by regularly reviewing industry publications, attending relevant conferences or webinars, and engaging in professional networks.

6. Establish effective communication channels with payers: Providers should establish open lines of communication with payers to clarify any questions or concerns regarding workers' compensation claims. By proactively engaging with payers, providers can address any potential issues and prevent denials associated with code P12.

7. Train staff on workers' compensation billing guidelines: Properly training staff members involved in the billing process is essential to prevent denials related to workers' compensation claims. Providers should ensure that their staff is well-versed in the specific guidelines and requirements for billing workers' compensation claims accurately.

By implementing these strategies, healthcare providers can mitigate code P12 and improve their revenue cycle management for workers' compensation claims.

How to Address Denial Code P12

The steps to address code P12, Workers' compensation jurisdictional fee schedule adjustment, are as follows:

1. If the adjustment is at the Claim Level:  

- The payer must send the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF).  

- The provider should review the 835 segment received from the payer.  

- If the regulations apply, the provider should take appropriate action based on the information provided in the segment.

2. If the adjustment is at the Line Level:  

- The payer must send the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply.  

- The provider should review the 835 segment received from the payer.  

- If the regulations apply, the provider should take appropriate action based on the information provided in the segment.

It is important to note that this code, P12, is specific to Workers' Compensation cases only. Providers should ensure that they are familiar with the relevant Workers' Compensation regulations and guidelines to appropriately address this code.

RARCs Associated to CARC P12

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