How To Fix Denial Code 170 | Common Reasons, Next Steps & How To Avoid It

Denial Code 170 means that payment is denied when performed or billed by a specific type of provider. This denial code is often accompanied by the 835 Healthcare Policy Identification Segment, which provides additional information about the denial. In this article, we will explore the description of denial code 170, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples of denial code 170 cases.

2. Description

Denial Code 170 is a specific denial code that indicates payment is denied when a service is performed or billed by a particular type of provider. The exact type of provider that triggers this denial code may vary depending on the specific insurance policy and guidelines. To gain further insight into the denial, it is recommended to refer to the 835 Healthcare Policy Identification Segment, if present, which can provide more detailed information about the denial and the specific provider type involved.

2. Common Reasons

There are several common reasons why denial code 170 may occur:

1. Out-of-Network Providers: One of the most common reasons for denial code 170 is when a service is performed or billed by an out-of-network provider. Insurance plans often have networks of preferred providers, and if a patient seeks care from a provider outside of this network, the claim may be denied under denial code 170.
2. Non-Covered Services: Denial code 170 may also be triggered when a service is not covered by the patient’s insurance plan. Certain procedures, treatments, or tests may be excluded from coverage, and if a provider performs or bills for these services, the claim may be denied.
3. Licensing or Credentialing Issues: Providers who do not have the necessary licenses or credentials to perform certain services may face denial code 170. Insurance companies require providers to meet specific qualifications and standards, and if a provider does not meet these requirements, the claim may be denied.
4. Incorrect Provider Type: Sometimes, claims may be denied under denial code 170 due to errors in the provider’s type or specialty designation. If the provider’s type or specialty does not align with the services being billed, the claim may be denied.
5. Policy Limitations: Certain insurance policies may have limitations on the types of providers or services covered. If a provider falls outside of these limitations, the claim may be denied under denial code 170.

3. Next Steps

If you receive a denial under code 170, here are the next steps to resolve it:

1. Review the Denial Explanation: Carefully review the denial explanation provided by the insurance company. Look for any specific information or instructions related to the denial code 170.
2. Verify Provider Information: Double-check the provider’s information, including their type, credentials, and licensing. Ensure that the provider meets the requirements set by the insurance company for the services being billed.
3. Contact the Insurance Company: Reach out to the insurance company’s provider support or claims department to discuss the denial. Provide any necessary documentation or clarification regarding the provider’s qualifications and the services performed.
4. Appeal the Denial: If you believe the denial was made in error or have additional information to support the claim, consider filing an appeal. Follow the insurance company’s appeal process and provide any relevant documentation or evidence to support your case.
5. Seek Provider Enrollment: If the denial was due to the provider’s lack of enrollment or credentialing, take the necessary steps to enroll or obtain the required credentials. This may involve completing applications, submitting documentation, or meeting specific criteria set by the insurance company.

4. How To Avoid It

To avoid denial code 170 in the future, consider the following steps:

1. Verify Provider Participation: Before providing services, verify the provider’s participation status with the patient’s insurance plan. Ensure that the provider is in-network and meets the plan’s requirements for the services being rendered.
2. Check Coverage for Services: Review the patient’s insurance policy to determine if the services being provided are covered. Be aware of any limitations or exclusions that may apply to certain procedures or treatments.
3. Stay Up-to-Date with Licensing and Credentialing: Regularly monitor and maintain the necessary licenses and credentials for the services being offered. Stay informed about any changes or updates to the requirements set by the insurance company.
4. Accurate Provider Type Designation: Ensure that the provider’s type or specialty designation accurately reflects the services being billed. Double-check the provider’s information to avoid any errors or discrepancies.
5. Communicate with the Insurance Company: Establish open lines of communication with the insurance company to clarify any questions or concerns regarding provider qualifications or coverage. Seek pre-authorization if necessary.

5. Example Cases

Here are two examples of denial code 170:

• Example 1: A patient seeks treatment from a specialist who is not in-network with their insurance plan. The claim for the specialist’s services is denied under denial code 170.
• Example 2: A provider mistakenly bills for a service that is not covered by the patient’s insurance policy. The claim is denied under denial code 170 due to the non-covered service.

Source: Claim Adjustment Reason Codes