How To Fix Denial Code 179 | Common Reasons, Next Steps & How To Avoid It

Denial Code 179 means that the patient has not met the required waiting requirements. This denial code indicates that the insurance company will not make the payment for the billed service because the patient has not fulfilled the waiting period specified in their policy. In this article, we will explore the description of denial code 179, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 179 is a specific Claim Adjustment Reason Code (CARC) that signifies that the patient has not met the required waiting requirements. This code is typically found in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) of the claim. It indicates that the insurance company will not reimburse the provider for the billed service because the patient has not fulfilled the waiting period specified in their policy. The waiting period is a predetermined period of time that the patient must wait before certain services or treatments are covered by their insurance.

2. Common Reasons

The most common reasons for denial code 179 are:

1. Insufficient Waiting Period: Denial code 179 may occur when the patient has not completed the required waiting period specified in their insurance policy. This waiting period is often imposed for specific services or treatments, such as elective surgeries or pre-existing conditions. If the patient seeks these services before the waiting period is over, the claim may be denied under code 179.
2. Lack of Documentation: Another reason for denial code 179 is the absence of proper documentation regarding the waiting period. If the provider fails to submit the necessary documentation to prove that the waiting period has been satisfied, the claim may be denied. This can include documentation such as pre-authorization forms or proof of prior waiting period completion.
3. Policy Exclusions: Some insurance policies may have exclusions that prevent coverage for certain services or treatments during the waiting period. If the patient seeks these excluded services before the waiting period is over, the claim may be denied under code 179.
4. Incorrect Coding: Inaccurate coding can also lead to denial code 179. If the service or treatment is coded incorrectly, it may not be recognized as subject to a waiting period, resulting in a denial.

3. Next Steps

To resolve denial code 179, the following steps can be taken:

1. Review Policy: First, review the patient’s insurance policy to understand the waiting period requirements for the specific service or treatment. Ensure that the patient has completed the required waiting period before submitting the claim.
2. Documentation Submission: If the waiting period has been completed but the claim was denied due to lack of documentation, gather the necessary evidence to prove that the waiting period has been satisfied. This may include pre-authorization forms, proof of prior waiting period completion, or any other relevant documentation required by the insurance company.
3. Appeal the Denial: If the denial was issued in error or if there are valid reasons to challenge the denial, consider filing an appeal. Provide all supporting documentation and a clear explanation of why the denial should be overturned.
4. Communication with Insurance: Engage in direct communication with the insurance company to clarify any misunderstandings or discrepancies regarding the waiting period. Discuss the specifics of the claim and provide any additional information or documentation requested by the insurer.

4. How To Avoid It

To avoid denial code 179 in the future, consider the following measures:

1. Policy Education: Educate patients about their insurance policy, including waiting period requirements. Clearly explain the waiting periods for specific services or treatments, ensuring that patients understand the limitations and coverage restrictions during these periods.
2. Pre-Verification: Before providing services or treatments, verify the patient’s insurance coverage and review the waiting period requirements. Ensure that the patient has completed the necessary waiting period before proceeding with the service.
3. Accurate Coding: Ensure accurate coding of services or treatments, including the appropriate indicators for waiting period requirements. This will help prevent denials due to coding errors or omissions.
4. Documentation Management: Maintain proper documentation of waiting periods, including pre-authorization forms and proof of prior waiting period completion. This will help support claims and prevent denials due to lack of documentation.

5. Example Cases

Here are two examples of denial code 179:

• Example 1: A patient undergoes elective surgery before the waiting period specified in their insurance policy has elapsed. As a result, the claim for the surgery is denied under code 179.
• Example 2: A provider fails to submit the necessary pre-authorization forms for a treatment subject to a waiting period. The claim is subsequently denied under code 179 due to lack of documentation.

Source: Claim Adjustment Reason Codes