Denial Code 163 means that the attachment or other documentation referenced on the claim was not received. Below you can find the description, common reasons for denial code 163, next steps, how to avoid it, and examples.
2. Description
Denial Code 163 is a Claim Adjustment Reason Code (CARC) that indicates that the attachment or other supporting documentation referenced on the claim was not received by the insurance company. This means that the claim cannot be processed or paid until the necessary documentation is provided. It is essential to submit all required documentation to support the services billed in order to avoid denial under Code 163.
2. Common Reasons
The most common reasons for denial code 163 are:
- Missing Documentation: One of the primary reasons for denial code 163 is the failure to include the required attachments or supporting documentation with the claim submission. This could include medical records, test results, referral letters, or any other documentation necessary to validate the services billed.
- Incomplete Documentation: Even if some documentation is provided, it may be incomplete or insufficient to support the services billed. Inadequate documentation can lead to denials under Code 163, as the insurance company requires complete and accurate information to process the claim.
- Untimely Submission: Another reason for denial code 163 is the late submission of the required documentation. Insurance companies often have specific timeframes within which supporting documentation must be submitted. Failure to meet these deadlines can result in denials under Code 163.
- Incorrect or Inaccurate Documentation: Denials under Code 163 can also occur if the submitted documentation contains errors or inaccuracies. This could include missing or incorrect patient information, illegible handwriting, or incomplete medical records. It is crucial to ensure that all documentation is accurate and complete to avoid denials.
- Non-Compliance with Documentation Guidelines: Insurance companies have specific guidelines and requirements for the type and format of documentation that must be submitted. Failure to comply with these guidelines can lead to denials under Code 163. It is essential to familiarize yourself with the documentation requirements of each insurance company to ensure compliance.
3. Next Steps
You can fix denial code 163 as follows:
- Review Claim and Documentation Requirements: Carefully review the denial code 163 and the specific documentation requirements outlined by the insurance company. Ensure that you understand what documentation is necessary to support the services billed.
- Identify Missing or Incomplete Documentation: Compare the submitted claim with the required documentation. Identify any missing or incomplete documentation that may have led to the denial. This step will help you determine what needs to be provided to resolve the denial.
- Obtain and Submit Missing Documentation: Obtain the missing or incomplete documentation and submit it to the insurance company as soon as possible. Ensure that the documentation is complete, accurate, and meets the specific requirements outlined by the insurance company.
- Follow Timely Submission Guidelines: Pay attention to the submission deadlines specified by the insurance company. Submit the required documentation within the specified timeframe to avoid further delays or denials.
- Document and Track Submissions: Keep a record of all documentation submitted, including dates and methods of submission. This documentation will be useful in case of any disputes or further inquiries from the insurance company.
- Follow Up with Insurance Company: After submitting the missing documentation, follow up with the insurance company to ensure that it has been received and processed. Keep track of any communication or correspondence related to the resolution of the denial.
4. How To Avoid It
You can prevent denial code 163 in the future as follows:
- Understand Documentation Requirements: Familiarize yourself with the documentation requirements of each insurance company you work with. Ensure that you have a clear understanding of what documentation is necessary to support the services billed.
- Implement Documentation Processes: Establish clear processes and protocols within your organization to ensure that all required documentation is obtained and submitted accurately and timely. This may involve creating checklists, training staff on documentation requirements, and implementing quality control measures.
- Double-Check Documentation: Before submitting a claim, double-check that all required documentation is included and meets the specific requirements outlined by the insurance company. Review for completeness, accuracy, and legibility.
- Stay Updated on Guidelines: Stay informed about any changes or updates to the documentation guidelines of the insurance companies you work with. Regularly review their policies and communicate any updates to your staff.
- Track Submission Deadlines: Keep track of the submission deadlines specified by each insurance company. Ensure that all required documentation is submitted within the specified timeframe to avoid denials under Code 163.
5. Example Cases
Below are two examples of denial code 163:
- Example 1: A healthcare provider submits a claim for a surgical procedure but fails to include the operative report as required by the insurance company. The claim is denied under Code 163 due to missing documentation.
- Example 2: A laboratory submits a claim for a diagnostic test but provides incomplete test results. The claim is denied under Code 163 as the documentation provided is insufficient to support the billed service.
