How To Fix Denial Code 211 | Common Reasons, Next Steps & How To Avoid It

Denial Code 211 means that the National Drug Codes (NDC) billed are not eligible for rebate and therefore not covered by the insurance company. In this article, we will provide a description of denial code 211, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code 211 cases.

2. Description

Denial Code 211 is a Claim Adjustment Reason Code (CARC) that indicates that the National Drug Codes (NDC) billed for a service or medication are not eligible for rebate and are therefore not covered by the insurance company. This means that the insurance company will not provide reimbursement for the specific NDCs listed on the claim.

2. Common Reasons

The most common reasons for denial code 211 are:

1. Ineligible NDCs: Denial code 211 occurs when the NDCs listed on the claim are not eligible for rebate according to the insurance company’s policies. This could be due to various factors such as the specific drug not being covered by the patient’s insurance plan or the NDC not meeting the requirements for rebate eligibility.
2. Missing or Incorrect NDC Information: If the NDC information provided on the claim is missing or incorrect, it can result in denial code 211. This could include errors in the NDC code itself, missing digits, or incorrect formatting. It is essential to ensure that the NDC information is accurate and up-to-date when submitting a claim.
3. Lack of Prior Authorization: Some insurance plans require prior authorization for certain medications or services. If the necessary prior authorization was not obtained before submitting the claim, it can lead to denial code 211. It is crucial to verify the insurance plan’s requirements and obtain any necessary authorizations before providing the service or medication.
4. Non-Covered Medications: Denial code 211 may occur if the specific medication listed on the claim is not covered by the patient’s insurance plan. This could be due to the medication being classified as non-formulary or not meeting the plan’s coverage criteria. It is important to verify the patient’s coverage for the medication before prescribing or administering it.

3. Next Steps

To resolve denial code 211, the following steps can be taken:

1. Review the Claim: Carefully review the claim to ensure that the NDC information provided is accurate and matches the medication or service provided. Check for any missing or incorrect NDC codes and correct them if necessary.
2. Verify Rebate Eligibility: Confirm with the insurance company whether the NDCs listed on the claim are eligible for rebate. If they are not eligible, explore alternative options for reimbursement or discuss with the patient the possibility of self-pay for the non-covered medication or service.
3. Obtain Prior Authorization: If the denial is due to a lack of prior authorization, contact the insurance company to initiate the authorization process. Provide any necessary documentation or information required to obtain the authorization. Once the authorization is obtained, resubmit the claim with the updated information.
4. Appeal the Denial: If you believe that the denial was incorrect or unjustified, you have the option to appeal the denial. Gather any supporting documentation, such as medical necessity or coverage criteria, and submit an appeal to the insurance company. Follow their specific appeals process and provide any additional information requested.
5. Communicate with the Patient: Keep the patient informed about the denial and the steps being taken to resolve it. Discuss any potential out-of-pocket costs they may incur if the medication or service is not covered by their insurance. Explore alternative options or assistance programs that may be available to help with the cost.

4. How To Avoid It

To avoid denial code 211 in the future, consider the following tips:

1. Verify Coverage: Before prescribing or administering a medication, verify the patient’s insurance coverage to ensure that the specific NDC is covered by their plan. Check the formulary or coverage criteria to confirm eligibility.
2. Obtain Prior Authorization: If the insurance plan requires prior authorization for certain medications or services, ensure that the necessary authorization is obtained before providing the service or medication. Familiarize yourself with the plan’s requirements and follow the authorization process.
3. Accurate NDC Information: Double-check the NDC information provided on the claim to ensure accuracy. Verify that the NDC code is correct, all necessary digits are included, and the formatting is accurate.
4. Stay Updated: Stay informed about changes in the insurance company’s policies regarding rebate eligibility for NDCs. Regularly review the formulary and coverage criteria to ensure that the medications or services provided are covered.

5. Example Cases

Here are two examples of denial code 211:

• Example 1: A healthcare provider submits a claim for a specific medication, but the insurance company’s formulary does not include that medication. As a result, the claim is denied under denial code 211.
• Example 2: The NDC code provided on the claim is missing a digit, resulting in an incorrect code. The insurance company denies the claim under denial code 211 due to the inaccurate NDC information.

Source: Claim Adjustment Reason Codes