How To Fix Denial Code 115 | Common Reasons, Next Steps & How To Avoid It

Denial Code 115 means that a claim has been denied because the procedure was postponed, canceled, or delayed. Below you can find the description, common reasons for denial code 115, next steps, how to avoid it, and examples.

2. Description

Denial Code 115 is a Claim Adjustment Reason Code (CARC) and is described as ‘Procedure postponed, canceled, or delayed’. This denial code indicates that the insurance company will not make the payment for the billed procedure because it was either postponed, canceled, or delayed. In simpler terms, the claim is not payable because the procedure did not take place as scheduled.

2. Common Reasons

The most common reasons for denial code 115 are:

1. Procedure Rescheduling: Denial code 115 often occurs when a scheduled procedure is rescheduled for a later date. This could be due to various reasons such as the unavailability of the healthcare provider, the patient’s request, or the need for further preparation or testing before the procedure can be safely performed.
2. Procedure Cancellation: If a procedure is canceled entirely, denial code 115 will be applied. This could happen due to unforeseen circumstances, patient non-compliance, or medical reasons that make the procedure unnecessary or unsafe to proceed with.
3. Procedure Delay: In some cases, a procedure may be delayed for reasons such as equipment malfunction, staffing issues, or emergencies that require immediate attention. Denial code 115 is used when the procedure is not performed as originally scheduled but is still planned for a future date.
4. Lack of Prior Authorization: Some insurance plans require prior authorization for certain procedures. If the procedure was not authorized by the insurance company before it was scheduled, denial code 115 may be applied.
5. Documentation Insufficiency: If the necessary documentation to support the need for the procedure is incomplete or missing, the claim may be denied under code 115. This could include medical records, test results, or other supporting documents that are required for the procedure to be deemed medically necessary.

3. Next Steps

You can address denial code 115 as follows:

1. Review the Reason for Denial: First, carefully review the reason provided for the denial under code 115. Determine whether the procedure was indeed postponed, canceled, or delayed, and if the denial is accurate based on the circumstances.
2. Reschedule or Reinstate the Procedure: If the denial is due to a rescheduled or delayed procedure, take the necessary steps to reschedule or reinstate the procedure as soon as possible. Ensure that all parties involved, including the patient, are informed of the new date and any additional requirements.
3. Obtain Prior Authorization: If the denial is due to a lack of prior authorization, work with the insurance company to obtain the necessary authorization for the procedure. Provide any required documentation or additional information to support the medical necessity of the procedure.
4. Complete Documentation: If the denial is due to insufficient documentation, ensure that all necessary documentation is complete and accurate. This may involve gathering medical records, test results, or other supporting documents to demonstrate the medical necessity of the procedure.
5. Appeal the Denial: If you believe the denial under code 115 was incorrect or unjustified, you have the option to appeal the decision. Prepare a strong appeal letter outlining the reasons why the procedure should be covered and provide any supporting evidence or documentation to strengthen your case.
6. Communicate with the Patient: Throughout the process, maintain open and clear communication with the patient. Keep them informed of the denial, the steps being taken to address it, and any potential financial implications they may face as a result of the denial.

4. How To Avoid It

You can prevent denial code 115 in the future by taking the following steps:

1. Verify Prior Authorization Requirements: Before scheduling any procedure, verify with the insurance company whether prior authorization is required. Understand the specific requirements and ensure that all necessary steps are taken to obtain the authorization before proceeding.
2. Communicate with the Insurance Company: Maintain open lines of communication with the insurance company. If there are any changes or updates to the scheduled procedure, inform the insurance company promptly to avoid any potential denials due to miscommunication or lack of information.
3. Complete and Accurate Documentation: Ensure that all documentation related to the procedure is complete, accurate, and supports the medical necessity of the procedure. This includes medical records, test results, and any other relevant documentation that may be required by the insurance company.
4. Stay Up-to-Date with Insurance Policies: Regularly review and stay informed about the insurance policies and procedures related to prior authorization, documentation requirements, and any other factors that may impact the coverage of procedures. This will help you proactively address any potential issues and avoid denials.

5. Example Cases

Below are two examples of denial code 115:

• Example 1: A patient was scheduled for a surgical procedure, but due to unforeseen complications, the procedure had to be canceled on the day of the surgery. The claim for the procedure would be denied under code 115.
• Example 2: A provider scheduled a diagnostic test for a patient without obtaining prior authorization from the insurance company. The claim for the test would be denied under code 115 due to the lack of prior authorization.

Source: Claim Adjustment Reason Codes