Denial Code 159 means that a claim has been denied because the service or procedure was provided as a result of terrorism. Below you can find the description, common reasons for denial code 159, next steps, how to avoid it, and examples.
2. Description
Denial Code 159 is a Claim Adjustment Reason Code (CARC) and is described as ‘Service/Procedure Resulting from Terrorism’. This code indicates that the insurance company will not make payment for the billed service or procedure because it is determined to be a result of terrorism. This denial is based on the policy of the insurance company and the regulations surrounding coverage for services related to acts of terrorism.
2. Common Reasons
The most common reasons for denial code 159 are:
- Service or Procedure Classified as Terrorism-Related: Denial code 159 is triggered when the service or procedure is determined to be directly related to an act of terrorism. Insurance companies have specific guidelines and policies regarding coverage for services in these circumstances, and if the claim falls within this category, it will be denied.
- Insufficient Documentation: In some cases, the denial may occur due to a lack of sufficient documentation supporting the claim. Insurance companies require detailed information and evidence to determine if a service or procedure is related to an act of terrorism. If the documentation provided is incomplete or does not meet the insurer’s requirements, the claim may be denied.
- Policy Exclusions: Some insurance policies may explicitly exclude coverage for services or procedures resulting from acts of terrorism. If the policy contains such exclusions, any claims related to terrorism will be denied under code 159.
- Non-Covered Services: Denial code 159 may also be used if the service or procedure is not covered under the patient’s insurance policy, regardless of whether it is related to terrorism or not. In such cases, the denial is not specific to the terrorism aspect but rather the lack of coverage for the particular service or procedure.
3. Next Steps
You can address denial code 159 as follows:
- Review Policy Coverage: First, review the patient’s insurance policy to determine if there are any specific exclusions related to services or procedures resulting from acts of terrorism. Understanding the policy’s coverage limitations will help determine the appropriate next steps.
- Documentation Review: If the claim was denied due to insufficient documentation, carefully review the requirements set by the insurance company. Ensure that all necessary information and evidence related to the service or procedure’s connection to terrorism is included in the claim. If any documentation is missing or incomplete, gather the required information and resubmit the claim with the additional supporting documentation.
- Appeal the Denial: If you believe the denial was made in error or if you have additional evidence to support the claim’s validity, consider appealing the denial. Follow the insurance company’s appeal process, providing any necessary documentation or explanations to support your case. Be prepared to provide clear and compelling evidence that the service or procedure is not related to terrorism or that it falls within the policy’s coverage guidelines.
- Seek Legal Advice: In complex cases or situations where the denial appears to be unjustified, it may be beneficial to seek legal advice. An attorney experienced in healthcare and insurance law can provide guidance on the best course of action and help navigate the appeals process.
4. How To Avoid It
To avoid denial code 159 in the future, consider the following:
- Review Insurance Policies: Before providing services or procedures, thoroughly review the patient’s insurance policy to understand any exclusions or limitations related to acts of terrorism. This will help manage expectations and prevent potential denials.
- Document Services Clearly: Ensure that all documentation related to services or procedures clearly indicates their purpose and connection to the patient’s medical condition. Clear and detailed documentation can help support claims and prevent denials based on terrorism-related criteria.
- Verify Coverage: Before performing any services or procedures, verify the patient’s coverage for the specific service or procedure. Confirm that it is not excluded under the policy and that there are no limitations related to acts of terrorism.
- Communicate with Patients: Clearly communicate with patients about their insurance coverage and any potential limitations or exclusions. Inform them about the possibility of denials related to acts of terrorism and discuss alternative options if necessary.
5. Example Cases
Below are two examples of denial code 159:
- Example 1: A patient undergoes a surgical procedure to treat injuries sustained in a terrorist attack. The insurance company denies the claim under code 159, stating that the procedure is directly related to an act of terrorism and is not covered under the policy.
- Example 2: A healthcare provider submits a claim for counseling services provided to a patient who experienced trauma as a result of a terrorist incident. The claim is denied under code 159 because the insurance policy explicitly excludes coverage for services related to acts of terrorism.
