How To Fix Denial Code 176 | Common Reasons, Next Steps & How To Avoid It

Denial Code 176 means that a claim has been denied because the prescription is not current. Below you can find the description, common reasons for denial code 176, next steps, how to avoid it, and examples.

2. Description

Denial Code 176 is a Claim Adjustment Reason Code (CARC) and is described as ‘Prescription is not current’. This denial code indicates that the insurance company will not make the payment for the billed service because the prescription provided is not up to date. In simpler terms, the claim is not payable until a current prescription is provided.

2. Common Reasons

The most common reasons for denial code 176 are:

1. Expired Prescription: Denial code 176 is often triggered when the prescription provided by the healthcare provider has expired. Insurance plans require prescriptions to be current and valid in order to cover the costs of services. If the prescription is outdated, the claim will be denied.
2. Missing Prescription: Another common reason for denial code 176 is when the claim is submitted without a prescription. Insurance companies typically require a valid prescription to be included with the claim in order to verify the medical necessity of the service. If no prescription is provided, the claim will be denied.
3. Incorrect Prescription Information: Denial code 176 can also occur if the prescription information provided on the claim is incorrect or incomplete. This could include missing or inaccurate details such as the patient’s name, medication dosage, or prescribing physician. Insurance companies require accurate prescription information to ensure proper coverage, and any discrepancies can result in a denial.
4. Non-Covered Medication: In some cases, denial code 176 may be triggered if the prescribed medication is not covered by the patient’s insurance plan. Insurance companies have formularies that outline which medications are covered, and if the prescribed medication is not on the formulary, the claim will be denied.
5. Prior Authorization Requirement: Certain medications may require prior authorization from the insurance company before they can be covered. If the healthcare provider fails to obtain the necessary prior authorization for a prescribed medication, the claim will be denied under code 176.

3. Next Steps

You can fix denial code 176 as follows:

1. Verify Prescription Expiration: First, check the expiration date on the prescription provided. Ensure that the prescription is still valid and has not expired. If it has expired, the patient will need to obtain a new prescription from their healthcare provider.
2. Include Prescription with Claim: Make sure that a current and valid prescription is included with the claim submission. Double-check that all necessary prescription information is included, such as the patient’s name, medication dosage, and prescribing physician.
3. Review Prescription Information: Take the time to review the prescription information for accuracy and completeness. Ensure that all details are correct and match the patient’s insurance records. If any discrepancies are found, correct them before resubmitting the claim.
4. Check Medication Coverage: Verify that the prescribed medication is covered by the patient’s insurance plan. If it is not covered, consider alternative medications that are on the formulary. If no suitable alternatives are available, discuss the situation with the patient and explore other options for obtaining the necessary medication.
5. Obtain Prior Authorization: If the prescribed medication requires prior authorization, work with the insurance company to obtain the necessary approval. Follow their specific procedures for submitting the prior authorization request and ensure that all required documentation is included.

4. How To Avoid It

You can prevent denial code 176 in the future as follows:

1. Stay Up to Date with Prescriptions: Regularly check the expiration dates on prescriptions and ensure that they are renewed in a timely manner. Keep track of when prescriptions need to be renewed and schedule appointments with healthcare providers accordingly.
2. Include Prescription Information Accurately: When submitting claims, make sure that all prescription information is entered accurately and completely. Double-check that the patient’s name, medication dosage, and prescribing physician are all correct. This will help avoid any discrepancies that could lead to a denial.
3. Verify Medication Coverage: Before prescribing a medication, check the patient’s insurance formulary to ensure that the medication is covered. If it is not covered, consider alternative medications that are on the formulary or explore other options for obtaining the necessary medication.
4. Follow Prior Authorization Procedures: If a medication requires prior authorization, familiarize yourself with the insurance company’s specific procedures for obtaining approval. Start the process early to allow for any necessary documentation or additional steps that may be required.

5. Example Cases

Below are two examples of denial code 176:

• Example 1: A healthcare provider submits a claim for a prescription medication, but the prescription provided has expired. The claim is denied under code 176, indicating that a current prescription is required for coverage.
• Example 2: A claim is submitted without a prescription for a medication that requires prior authorization. The claim is denied under code 176, as the necessary documentation was not included.

Source: Claim Adjustment Reason Codes