How To Fix Denial Code 132 | Common Reasons, Next Steps & How To Avoid It

Denial Code 132 means that a claim has been adjusted due to a prearranged demonstration project. Below you can find the description, common reasons for denial code 132, next steps, how to avoid it, and examples.

2. Description

Denial Code 132 is a claim adjustment reason code (CARC) that indicates a prearranged demonstration project adjustment. This means that the claim has been adjusted or modified as part of a demonstration project that has been prearranged with the insurance company. The specific details of the adjustment will depend on the terms and conditions of the demonstration project.

2. Common Reasons

The common reasons for denial code 132 are:

1. Participation in Demonstration Project: The primary reason for denial code 132 is that the claim is subject to a prearranged demonstration project. This could be a pilot program or a research study that aims to test new payment models, evaluate the effectiveness of certain treatments, or assess the impact of specific interventions. The insurance company may adjust the claim based on the terms and conditions of the demonstration project.
2. Non-Compliance with Project Requirements: Another reason for denial code 132 could be non-compliance with the requirements of the demonstration project. If the provider or the patient fails to meet the criteria or follow the protocols outlined in the project, the claim may be adjusted or denied.
3. Exclusion from Project Coverage: Some claims may be denied under code 132 if they fall outside the scope of the demonstration project. If the services or treatments provided are not included in the project’s coverage, the claim may be adjusted or denied.
4. Incomplete or Inaccurate Documentation: Claims that lack the necessary documentation or contain inaccuracies may be subject to denial code 132. Proper documentation is essential for demonstrating compliance with the project requirements and ensuring accurate claim processing.
5. Expired or Invalid Project Participation: If the demonstration project has expired or the provider’s participation has been terminated, claims submitted after the expiration or termination date may be denied under code 132.

3. Next Steps

To address denial code 132, follow these steps:

1. Review Project Details: Start by reviewing the details of the prearranged demonstration project. Understand the specific requirements, coverage limitations, and any other relevant information that may impact claim processing.
2. Verify Compliance: Ensure that you and your staff are fully compliant with the requirements of the demonstration project. This may involve training, documentation, or specific protocols that need to be followed. Non-compliance can result in claim adjustments or denials.
3. Check Documentation: Double-check that all necessary documentation is complete, accurate, and meets the project’s requirements. This includes any additional documentation or supporting evidence that may be required for claim submission.
4. Resubmit or Appeal: If the claim has been denied under code 132 due to an error or misunderstanding, you may need to resubmit the claim with additional documentation or appeal the denial. Follow the specific procedures outlined by the insurance company or the project administrators.
5. Stay Informed: Keep yourself updated on any changes or updates to the demonstration project. This will help you ensure ongoing compliance and avoid potential denials or claim adjustments.

4. How To Avoid It

To avoid denial code 132 in the future, consider the following:

1. Understand Project Requirements: Before participating in any demonstration project, thoroughly understand the requirements, limitations, and coverage details. This will help you determine if the project aligns with your practice and if you can meet the necessary criteria.
2. Comply with Protocols: Strictly adhere to the protocols and guidelines outlined in the demonstration project. This includes following specific treatment plans, documenting patient progress, and submitting claims according to the project’s requirements.
3. Document Carefully: Maintain accurate and comprehensive documentation for all services provided as part of the demonstration project. This includes detailed records of treatments, interventions, and patient outcomes. Proper documentation will support your claims and help avoid denials.
4. Stay Updated: Stay informed about any changes or updates to the demonstration project. This may include modifications to coverage, requirements, or project timelines. Regularly review project communications and stay in touch with project administrators.

5. Example Cases

Below are two examples of denial code 132:

• Example 1: A healthcare provider participates in a demonstration project focused on reducing hospital readmissions. The provider submits a claim for a patient who was readmitted within 30 days of discharge. The claim is adjusted under code 132 to reflect the project’s payment model, which may differ from the standard reimbursement rates.
• Example 2: A provider submits a claim for a service that is not covered under the terms of the demonstration project. The claim is denied under code 132, indicating that the service falls outside the project’s scope and is not eligible for reimbursement.

Source: Claim Adjustment Reason Codes