Denial Code 158 (CARC) means that a claim has been denied because the service or procedure was provided outside of the United States. Below you can find the description, common reasons for denial code 158, next steps, how to avoid it, and examples.
2. Description
Denial Code 158 is a Claim Adjustment Reason Code (CARC) and is described as ‘Service/Procedure Provided Outside of the United States’. This denial code indicates that the insurance company will not make payment for the billed service because it was performed outside of the United States. In simpler terms, the claim is not payable if the service or procedure was not conducted within the country’s borders.
2. Common Reasons
The most common reasons for denial code 158 are:
- International Service: Denial code 158 is triggered when a healthcare service or procedure is performed outside of the United States. Insurance plans typically have limitations on coverage for services provided internationally, and as a result, claims for such services are denied.
- Lack of Prior Authorization: Some insurance plans require prior authorization for services performed outside of the United States. If the necessary authorization was not obtained before the service was rendered, the claim may be denied under code 158.
- Out-of-Network Provider: Insurance plans often have networks of preferred providers within the United States. If a patient receives care from a provider who is not within the network while outside of the country, the claim may be denied under code 158.
- Excluded Services: Certain insurance plans have specific exclusions for services provided outside of the United States. If the service falls under one of these exclusions, the claim will be denied under code 158.
- Incomplete Documentation: Claims for services provided outside of the United States may require additional documentation to support the medical necessity and appropriateness of the service. If the necessary documentation is not provided, the claim may be denied under code 158.
3. Next Steps
You can address denial code 158 as follows:
- Review Coverage Policy: Familiarize yourself with the insurance plan’s coverage policy regarding services provided outside of the United States. Understand the limitations, requirements for prior authorization, and any exclusions that may apply.
- Prior Authorization: If prior authorization is required for international services, ensure that it is obtained before the service is rendered. Work closely with the patient and their insurance company to navigate the authorization process and gather all necessary documentation.
- Appeal the Denial: If you believe the denial was in error or if you have additional documentation to support the medical necessity of the service, consider appealing the denial. Follow the insurance company’s appeal process and provide all relevant information to support your case.
- Communicate with the Patient: Keep the patient informed about the denial and the reasons behind it. Discuss any potential out-of-pocket expenses they may incur due to the denial and explore alternative options for their healthcare needs.
- Explore Alternative Coverage: In some cases, patients may have additional insurance coverage that includes benefits for services provided outside of the United States. Help the patient understand their options and guide them towards utilizing the appropriate coverage.
4. How To Avoid It
You can prevent denial code 158 in the future by taking the following steps:
- Verify Coverage: Before providing any services, verify the patient’s insurance coverage and review the policy for any limitations or exclusions related to services provided outside of the United States.
- Obtain Prior Authorization: If the insurance plan requires prior authorization for international services, ensure that it is obtained before the service is rendered. Familiarize yourself with the authorization process and gather all necessary documentation.
- Communicate with Patients: Educate patients about their insurance coverage and any limitations or exclusions that may apply to services provided outside of the United States. Encourage them to contact their insurance company directly if they have any questions or concerns.
- Network Providers: Whenever possible, refer patients to providers within their insurance plan’s network. This reduces the likelihood of denials due to out-of-network services provided outside of the United States.
- Thorough Documentation: Ensure that all documentation supporting the medical necessity and appropriateness of the service is complete and accurate. Include any additional documentation required for services provided outside of the United States.
5. Example Cases
Below are two examples of denial code 158:
- Example 1: A patient travels to Mexico for a dental procedure and submits a claim to their insurance company. The claim is denied under code 158 because the service was provided outside of the United States.
- Example 2: A patient undergoes a medical procedure in Canada without obtaining prior authorization from their insurance company. The claim is denied under code 158 due to the lack of authorization for services provided outside of the United States.
