How To Fix Denial Code 117 | Common Reasons, Next Steps & How To Avoid It

Denial Code 117 means that transportation is only covered to the closest facility that can provide the necessary care. This denial code indicates that the insurance company will not reimburse for transportation expenses if the patient could have received the required care at a closer facility. In this article, we will explore the description of denial code 117, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 117 is a claim adjustment reason code (CARC) that specifically addresses transportation coverage. It signifies that the insurance company will only provide reimbursement for transportation expenses if the patient had to travel to the closest facility that could offer the necessary care. If the patient could have received the required treatment at a facility closer to their location, the transportation costs will not be covered.

2. Common Reasons

The most common reasons for denial code 117 are:

1. Proximity to Care: Denial code 117 is often triggered when the patient chooses to seek treatment at a facility that is not the closest option available. If there is a closer facility that can provide the necessary care, the insurance company will deny coverage for transportation expenses.
2. Lack of Medical Necessity: Another common reason for denial code 117 is when the insurance company determines that the transportation was not medically necessary. If the patient’s condition does not require specialized care that is only available at a distant facility, the insurance company may deny coverage for transportation costs.
3. Out-of-Network Providers: Denial code 117 may also occur when the patient chooses to receive treatment from an out-of-network provider. If there is an in-network provider closer to the patient’s location who can offer the required care, the insurance company may deny coverage for transportation expenses.
4. Failure to Obtain Prior Authorization: In some cases, denial code 117 may be triggered if the patient or healthcare provider failed to obtain prior authorization for transportation expenses. Insurance companies often require pre-approval for transportation services to ensure that they are medically necessary and cost-effective.

3. Next Steps

If you encounter denial code 117, here are the next steps to resolve it:

1. Review the Denial Explanation: Carefully review the explanation provided by the insurance company for the denial. Understand the specific reason for denial code 117 and gather any additional information or documentation that may be required to support your case.
2. Appeal the Denial: If you believe that the denial was incorrect or unjustified, file an appeal with the insurance company. Provide any necessary documentation, such as medical records or a letter from the treating physician, to demonstrate the medical necessity of the transportation expenses.
3. Consider Alternative Options: If the denial is upheld, explore alternative options for transportation. This may include seeking care at a closer facility or exploring other means of transportation, such as public transportation or rideshare services.
4. Communicate with the Patient: Keep the patient informed throughout the process and discuss any potential out-of-pocket expenses they may incur due to the denial. Provide them with information on alternative facilities or transportation options that may be more cost-effective.
5. Document and Track Expenses: Keep detailed records of all expenses related to transportation and the denial. This documentation will be valuable if you need to provide evidence of the financial impact of the denial or if you decide to pursue further action.

4. How To Avoid It

To avoid denial code 117 in the future, consider the following steps:

1. Verify Network Coverage: Before scheduling or recommending treatment at a specific facility, verify that it is within the patient’s network. Ensure that the facility is in-network and that the insurance plan covers transportation expenses to that facility.
2. Assess Medical Necessity: Evaluate the medical necessity of transportation expenses before submitting a claim. If the patient’s condition does not require specialized care that is only available at a distant facility, consider exploring closer options to avoid potential denials.
3. Obtain Prior Authorization: Work closely with the insurance company to obtain prior authorization for transportation expenses when necessary. Follow their guidelines and requirements to ensure that the transportation is deemed medically necessary and eligible for reimbursement.
4. Educate Patients: Educate patients about their insurance coverage and the importance of seeking care at in-network facilities whenever possible. Encourage them to contact their insurance company or consult with you before making decisions about treatment locations.

5. Example Cases

Here are two examples of denial code 117:

• Example 1: A patient with a specific medical condition chooses to travel to a renowned specialist located in another state, bypassing several closer facilities that could provide the same level of care. The insurance company denies coverage for transportation expenses, citing denial code 117.
• Example 2: A patient requires a routine procedure that can be performed at multiple facilities within their network. However, they choose to go to an out-of-network facility that is farther away. The insurance company denies coverage for transportation costs, citing denial code 117.

Source: Claim Adjustment Reason Codes