How To Fix Denial Code 118 | Common Reasons, Next Steps & How To Avoid It

Denial Code 118 means that a claim has been adjusted due to ESRD network support. Below you can find the description, common reasons for denial code 118, next steps, how to avoid it, and examples.

2. Description

Denial Code 118 is an adjustment code related to ESRD network support. ESRD stands for End-Stage Renal Disease, which is a condition where the kidneys are no longer able to function properly. This denial code indicates that the claim has been adjusted due to specific requirements or limitations set by the ESRD network support program. The exact details of the adjustment may vary depending on the specific program and its guidelines.

2. Common Reasons

The most common reasons for denial code 118 are:

1. Non-Compliance with ESRD Network Support Program: Denial code 118 may occur if the provider or patient fails to comply with the requirements of the ESRD network support program. This could include failure to submit necessary documentation, incomplete or inaccurate information, or not meeting the eligibility criteria set by the program.
2. Exceeding Program Limitations: Some ESRD network support programs have limitations on the types of services or treatments that are covered. If the claim includes services or treatments that are not within the scope of the program, it may be denied under code 118.
3. Missing or Incomplete Documentation: Claims may be denied if the necessary documentation to support the services provided is missing or incomplete. This could include medical records, test results, or other supporting documents required by the ESRD network support program.
4. Incorrect Coding or Billing Information: Errors in coding or billing information can lead to denials under code 118. This could include using incorrect procedure codes, diagnosis codes, or billing for services that are not covered by the ESRD network support program.
5. Expired or Inactive ESRD Network Support Program: If the ESRD network support program has expired or is no longer active, claims may be denied under code 118. It is important to regularly check the status of the program and ensure that it is still in effect before submitting claims.

3. Next Steps

You can address denial code 118 by following these steps:

1. Review ESRD Network Support Program Requirements: Familiarize yourself with the specific requirements and guidelines of the ESRD network support program. Ensure that you understand the eligibility criteria, covered services, and any limitations or restrictions that may apply.
2. Check for Compliance: Verify that both the provider and the patient are in compliance with the ESRD network support program requirements. Ensure that all necessary documentation is complete, accurate, and submitted in a timely manner. Confirm that the services provided are within the scope of the program.
3. Resubmit with Corrected Information: If the denial was due to missing or incomplete documentation, incorrect coding, or other errors, make the necessary corrections and resubmit the claim with the updated information. Ensure that all required documentation is included and that the coding accurately reflects the services provided.
4. Appeal if Necessary: If you believe that the denial was incorrect or unjustified, you have the option to appeal the decision. Follow the appeals process outlined by the ESRD network support program and provide any additional documentation or information that supports your case.
5. Stay Updated: Regularly check the status of the ESRD network support program to ensure that it is still active and that any changes or updates to the program are taken into account when submitting claims. Stay informed about any new requirements or guidelines that may be implemented.

4. How To Avoid It

To avoid denial code 118 in the future, consider the following steps:

1. Thoroughly Understand the ESRD Network Support Program: Take the time to fully understand the requirements, limitations, and guidelines of the ESRD network support program. This will help you ensure that claims are submitted correctly and in compliance with the program’s rules.
2. Double-Check Documentation: Before submitting a claim, carefully review all documentation to ensure that it is complete, accurate, and meets the requirements of the ESRD network support program. This includes medical records, test results, and any other supporting documents.
3. Accurate Coding and Billing: Use the correct procedure codes, diagnosis codes, and billing information when submitting claims. Make sure that the services being billed are covered by the ESRD network support program and that the coding accurately reflects the services provided.
4. Stay Informed: Stay updated on any changes or updates to the ESRD network support program. Regularly check for new guidelines, limitations, or requirements that may affect the submission of claims.

5. Example Cases

Below are two examples of denial code 118:

• Example 1: A provider submits a claim for a specialized treatment for a patient with ESRD. However, the treatment is not covered by the specific ESRD network support program that the patient is enrolled in, resulting in a denial under code 118.
• Example 2: A claim is denied under code 118 because the provider failed to submit the required documentation to support the services provided. Without the necessary documentation, the claim cannot be processed by the ESRD network support program.

Source: Claim Adjustment Reason Codes