DENIAL CODES

Denial code P24

Denial code P24 is a payment adjustment based on a Preferred Provider Organization (PPO). It is used for Property and Casualty claims and should be referred to the 835 Class of Contract Code Identification Segment or the 835 Healthcare Policy Identification Segment for more information. Use with Group Code CO.

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What is Denial Code P24

Denial code P24 is used when a payment is adjusted based on a Preferred Provider Organization (PPO). If the adjustment is at the claim level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If the adjustment is at the line level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. This denial code is specifically used for Property and Casualty cases only and should be used in conjunction with Group Code CO.

Common Causes of CARC P24

Common causes of code P24 are:

1. The claim was submitted to a Preferred Provider Organization (PPO) and the payment was adjusted based on the terms of the PPO contract.

2. The adjustment was made at the claim level, and the payer has provided additional information in the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF) that the provider should refer to.

3. The adjustment was made at the line level, and the payer has provided additional information in the 835 Healthcare Policy Identification Segment (Loop 2110 Service Payment Information REF) that the provider should refer to if the regulations apply.

4. This code is specific to Property and Casualty claims only and should be used in conjunction with Group Code CO.

Ways to Mitigate Denial Code P24

Ways to mitigate code P24 include:

1. Ensure accurate and up-to-date contract information: Maintain a comprehensive database of all contracts with Preferred Provider Organizations (PPOs). Regularly review and update the terms and conditions of these contracts to ensure that they align with the services provided and the reimbursement rates agreed upon.

2. Verify eligibility and benefits: Before providing services to a patient, verify their eligibility and benefits with the PPO. This will help identify any potential coverage limitations or exclusions that may result in payment adjustments.

3. Accurate coding and documentation: Ensure that all services provided are accurately coded and documented. Use the appropriate coding guidelines and documentation requirements to support the medical necessity and level of care provided. This will help minimize the chances of payment adjustments based on coding errors or insufficient documentation.

4. Timely claim submission: Submit claims to the PPO in a timely manner, adhering to their specific submission deadlines. Delayed or late submissions may result in payment adjustments or denials.

5. Monitor and appeal denied claims: Regularly monitor claim denials and payment adjustments related to code P24. Implement a robust denial management process to identify trends and patterns. If a denial is deemed incorrect or unjustified, promptly appeal the decision with supporting documentation and evidence.

6. Stay updated with regulatory changes: Stay informed about any changes in regulations or policies related to PPO reimbursements. Regularly review industry updates, attend relevant webinars or conferences, and engage with professional associations to stay up-to-date with the latest changes.

7. Implement effective revenue cycle management (RCM) practices: Establish efficient RCM processes that include thorough verification of patient information, accurate coding and documentation, timely claim submission, and proactive denial management. This will help minimize payment adjustments and improve overall revenue capture.

Remember, it is essential to consult with your organization's legal and compliance teams to ensure that all strategies align with applicable laws, regulations, and contractual obligations.

How to Address Denial Code P24

The steps to address code P24 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 to understand the specific details of the adjustment.  

- The provider should compare the adjustment information with the terms and conditions of the contract with the Preferred Provider Organization (PPO).  

- If there are any discrepancies or concerns, the provider should reach out to the payer's representative or the PPO's contracting department for clarification or resolution.

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 to understand the specific details of the adjustment at the line level.  

- The provider should cross-reference the adjustment information with the applicable healthcare policies.  

- If there are any questions or discrepancies, the provider should contact the payer's representative or the appropriate department responsible for policy interpretation and compliance.  

It is important for healthcare providers to thoroughly review and understand the adjustment codes received, as they can impact the reimbursement and revenue cycle. By following these steps, providers can effectively address code P24 and ensure accurate payment based on the terms of the PPO contract or applicable healthcare policies.

RARCs Associated to CARC P24

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