Denial Code 111 means that a claim has been denied because the service is not covered unless the provider accepts assignment. Below you can find the description, common reasons for denial code 111, next steps, how to avoid it, and examples.
2. Description
Denial Code 111 is a Claim Adjustment Reason Code (CARC) and is described as ‘Not covered unless the provider accepts assignment’. This denial code indicates that the insurance company will not make payment for the billed service unless the healthcare provider accepts assignment. In simpler terms, the provider must agree to accept the insurance company’s approved amount as full payment for the service in order for the claim to be payable.
2. Common Reasons
The most common reasons for denial code 111 are:
- Non-Participating Provider: Denial code 111 often occurs when the healthcare provider is not a participating provider in the patient’s insurance network. Insurance plans typically have a network of preferred providers who have agreed to accept assignment and adhere to the insurance company’s approved rates. If the provider is not part of this network, the claim may be denied under code 111.
- Out-of-Network Services: Another common reason for denial code 111 is when the patient receives services from an out-of-network provider. Insurance plans often have different coverage levels for in-network and out-of-network services. If the provider is out-of-network and does not accept assignment, the claim may be denied under code 111.
- Provider Agreement Issues: Denial code 111 can also occur if there are issues with the provider’s agreement with the insurance company. This could include expired agreements, disputes over reimbursement rates, or other contractual issues that prevent the provider from accepting assignment.
- Service Not Covered: In some cases, denial code 111 may be triggered if the specific service or procedure is not covered by the patient’s insurance plan. Even if the provider accepts assignment, the claim will be denied because the service falls outside the scope of coverage.
- Missing or Incomplete Provider Information: Claims may be denied under code 111 if there are missing or incomplete provider information, such as incorrect National Provider Identifier (NPI) or other required identifiers. Without accurate provider information, the insurance company may not be able to determine if the provider accepts assignment, leading to a denial.
3. Next Steps
You can fix denial code 111 as follows:
- Verify Provider Participation: First, confirm if the healthcare provider is a participating provider in the patient’s insurance network. Contact the insurance company or check their provider directory to ensure that the provider accepts assignment.
- Review Network Coverage: If the provider is out-of-network, review the patient’s insurance plan to determine if out-of-network services are covered. If not, consider referring the patient to an in-network provider who accepts assignment.
- Update Provider Agreements: If there are issues with the provider’s agreement with the insurance company, work with the provider to resolve any contractual issues. This may involve renegotiating reimbursement rates or addressing any other concerns that prevent the provider from accepting assignment.
- Check Service Coverage: Verify if the specific service or procedure is covered by the patient’s insurance plan. If not, inform the patient and explore alternative options or discuss self-pay arrangements.
- Ensure Complete Provider Information: Double-check that all required provider information, such as the NPI, is accurately included in the claim. This will help the insurance company determine if the provider accepts assignment and avoid denials under code 111 due to missing or incomplete information.
4. How To Avoid It
You can prevent denial code 111 in the future as follows:
- Participating Provider Status: Ensure that the healthcare provider is a participating provider in the patient’s insurance network. This can be verified by regularly checking the provider’s participation status with the insurance company.
- Network Coverage: Educate patients about the importance of receiving services from in-network providers who accept assignment. Inform them about the potential financial implications of seeking out-of-network care.
- Provider Agreements: Regularly review and update provider agreements with insurance companies to ensure that the provider is able to accept assignment and adhere to the insurance company’s approved rates.
- Service Coverage: Before providing services, verify if the specific service or procedure is covered by the patient’s insurance plan. If not, discuss alternative options or self-pay arrangements with the patient.
- Accurate Provider Information: Maintain accurate and up-to-date provider information, including the NPI, to avoid denials under code 111 due to missing or incomplete information.
5. Example Cases
Below are two examples of denial code 111:
- Example 1: A patient visits a specialist who is not a participating provider in their insurance network. The specialist does not accept assignment, resulting in denial code 111 for the claim.
- Example 2: A patient receives an out-of-network service from a provider who does not accept assignment. The claim is denied under code 111 due to the provider’s non-participating status.
