How To Fix Denial Code 215 | Common Reasons, Next Steps & How To Avoid It

Denial Code 215 means that a claim has been denied based on the subrogation of a third-party settlement. Below you can find the description, common reasons for denial code 215, next steps, how to avoid it, and examples.

2. Description

Denial Code 215 is a Claim Adjustment Reason Code (CARC) that indicates a claim has been denied due to the subrogation of a third-party settlement. Subrogation refers to the process where an insurance company seeks reimbursement from a responsible third party for medical expenses it has paid on behalf of the insured. In simpler terms, the claim is denied because the insurance company is pursuing recovery from another party to cover the costs of the services rendered.

2. Common Reasons

The most common reasons for denial code 215 are:

1. Third-Party Settlement: Denial code 215 is triggered when the insurance company has identified a third party who may be responsible for the medical expenses incurred by the insured. This could be due to an accident, injury, or other circumstances where another party may be liable for the costs.
2. Subrogation Process: The denial may occur if the insurance company is in the process of pursuing subrogation from the responsible third party. This means that the insurer is seeking reimbursement for the medical expenses it has already paid on behalf of the insured.
3. Insufficient Documentation: If the necessary documentation to support the subrogation claim is not provided or is incomplete, the claim may be denied under code 215. This could include missing accident reports, police reports, or other evidence that establishes the liability of the third party.
4. Disputed Liability: In some cases, the responsible third party may dispute their liability for the medical expenses. This can lead to a denial under code 215 until the dispute is resolved or a determination is made regarding the liability of the third party.
5. Coordination of Benefits: Denial code 215 may also occur when there is a coordination of benefits issue between multiple insurance policies. If another insurance policy is identified as the primary payer for the medical expenses, the claim may be denied under code 215 until the coordination of benefits is properly established.

3. Next Steps

You can address denial code 215 as follows:

1. Review Subrogation Process: Understand the subrogation process and the specific requirements of the insurance company for pursuing reimbursement from a third party. Familiarize yourself with the necessary documentation and steps involved in the subrogation process.
2. Gather Documentation: Collect all relevant documentation to support the subrogation claim. This may include accident reports, police reports, witness statements, or any other evidence that establishes the liability of the responsible third party.
3. Submit Subrogation Claim: Once you have gathered all the necessary documentation, submit the subrogation claim to the insurance company. Ensure that all required forms and supporting evidence are included to strengthen your case for reimbursement.
4. Follow Up: Stay in communication with the insurance company regarding the status of the subrogation claim. Provide any additional information or documentation that may be requested to support the claim. Keep track of all correspondence and maintain a record of your efforts to pursue reimbursement.
5. Appeal if Necessary: If the claim is denied under code 215 due to insufficient documentation or a disputed liability, consider appealing the denial. Provide any additional evidence or arguments that support your case for reimbursement. Consult with legal counsel if needed to navigate the appeals process.
6. Coordinate Benefits: If there are multiple insurance policies involved, ensure that the coordination of benefits is properly established. Determine which policy is the primary payer for the medical expenses and provide the necessary information to the insurance company to avoid denials under code 215.

4. How To Avoid It

You can prevent denial code 215 in the future by taking the following steps:

1. Verify Liability: Before submitting a claim, verify if there is a responsible third party who may be liable for the medical expenses. This could include conducting a thorough investigation into the circumstances surrounding the injury or accident.
2. Collect Documentation: Gather all relevant documentation that establishes the liability of the responsible third party. This may include accident reports, police reports, witness statements, or any other evidence that supports your claim.
3. Submit Subrogation Claim Early: If you believe that a third party is responsible for the medical expenses, submit the subrogation claim to the insurance company as early as possible. This allows for timely processing and reduces the likelihood of denials under code 215.
4. Ensure Complete Documentation: Double-check that all required documentation is included with the subrogation claim. This includes any forms, reports, or evidence that supports your case for reimbursement.
5. Coordinate Benefits: If there are multiple insurance policies involved, ensure that the coordination of benefits is properly established. Provide the necessary information to the insurance company to avoid denials under code 215.

5. Example Cases

Below are two examples of denial code 215:

• Example 1: A patient is involved in a car accident and sustains injuries. The insurance company denies the claim under code 215 because they believe another driver is responsible for the medical expenses and are pursuing subrogation from that driver’s insurance company.
• Example 2: A patient slips and falls in a grocery store, resulting in injuries. The insurance company denies the claim under code 215 as they believe the grocery store may be liable for the medical expenses and are pursuing subrogation from the store’s liability insurance.

Source: Claim Adjustment Reason Codes