Denial Code 184 means that the prescribing/ordering provider is not eligible to prescribe/order the service billed. This denial code indicates that the insurance company will not make payment for the service because the provider does not have the necessary credentials or authorization to perform or order the specific service. In this article, we will explore the common reasons for denial code 184, the next steps to take when faced with this denial, how to avoid it in the future, and provide examples to illustrate its application.
2. Description
Denial Code 184 is a specific Claim Adjustment Reason Code (CARC) that signifies that the prescribing or ordering provider is not eligible to perform or order the service being billed. This denial code is typically used when the provider does not have the required credentials, authorization, or licensing to perform the specific service. It is important to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) for further details on the specific eligibility criteria that were not met.
2. Common Reasons
The most common reasons for denial code 184 include:
- Lack of Proper Credentials: Providers may receive denial code 184 if they do not possess the necessary credentials or qualifications to perform or order the service in question. This could be due to a lack of specialized training, certification, or licensing required by the insurance company or regulatory bodies.
- Expired or Invalid Authorization: Denial code 184 may be triggered if the provider’s authorization to perform or order the service has expired or is deemed invalid by the insurance company. This could occur if the authorization was not renewed in a timely manner or if there were changes in the provider’s status that rendered the authorization invalid.
- Out-of-Network Provider: Insurance plans often have specific networks of providers with whom they have negotiated contracts and established reimbursement rates. If the provider is not part of the insurance company’s network, they may receive denial code 184 as they are not eligible to provide services covered by the patient’s insurance plan.
- Service Not Within Provider’s Scope: Denial code 184 can be issued if the service being billed is outside the scope of practice or expertise of the provider. This could occur if the provider is attempting to bill for a service that they are not qualified or authorized to perform, leading to a denial of payment.
- Missing or Incomplete Documentation: Insufficient or incomplete documentation supporting the provider’s eligibility to perform or order the service can result in denial code 184. This may include missing or expired licenses, certifications, or authorizations that are required by the insurance company to validate the claim.
3. Next Steps
If you receive denial code 184, follow these next steps to address the issue:
- Review the Denial Explanation: Carefully review the denial explanation provided by the insurance company, paying close attention to the specific eligibility criteria that were not met. This will help you understand the exact reason for the denial and guide your next steps.
- Verify Provider Credentials: Confirm that the provider possesses the necessary credentials, qualifications, and authorizations to perform or order the service. Check for any expired licenses or certifications that may have contributed to the denial. If there are any discrepancies, take steps to rectify them, such as renewing licenses or obtaining the required authorizations.
- Contact the Insurance Company: Reach out to the insurance company’s provider support or claims department to discuss the denial and seek clarification on the specific eligibility requirements that were not met. Provide any additional documentation or information that supports the provider’s eligibility to perform or order the service.
- Appeal the Denial: If you believe the denial was issued in error or have additional evidence to support the provider’s eligibility, consider filing an appeal. Follow the insurance company’s appeal process, providing all necessary documentation and explanations to support your case.
- Collaborate with the Patient: Communicate with the patient to inform them of the denial and discuss alternative options. Explore whether the service can be performed or ordered by another eligible provider or if there are alternative treatments available that are covered by the patient’s insurance plan.
4. How To Avoid It
To avoid denial code 184 in the future, consider the following steps:
- Verify Provider Eligibility: Before performing or ordering any services, ensure that the provider has the necessary credentials, qualifications, and authorizations to perform or order the specific service. Regularly review and update licenses, certifications, and authorizations to avoid any lapses.
- Stay In-Network: If possible, ensure that the provider is part of the patient’s insurance network. This will help avoid denials related to out-of-network providers. Regularly review and update network participation agreements to ensure continued eligibility.
- Stay Within Scope of Practice: Providers should only perform or order services that fall within their scope of practice and expertise. Regularly review and update knowledge and skills to ensure that services provided align with the provider’s qualifications.
- Maintain Accurate Documentation: Keep thorough and up-to-date documentation of all licenses, certifications, and authorizations. Regularly review and update documentation to ensure compliance with insurance company requirements.
5. Example Cases
Here are two examples illustrating denial code 184:
- Example 1: A chiropractor submits a claim for a surgical procedure. Since chiropractors are not authorized to perform surgical procedures, the claim is denied under code 184.
- Example 2: A provider’s license to prescribe controlled substances has expired. When attempting to bill for a prescription of a controlled substance, the claim is denied under code 184 due to the provider’s lack of authorization.
