How To Fix Denial Code 22 | Common Reasons, Next Steps & How To Avoid It

Denial Code 22 means that the care may be covered by another payer per coordination of benefits. In this article, we will provide a detailed description of denial code 22, 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 22 cases.

2. Description

Denial Code 22 is a Claim Adjustment Reason Code (CARC) that indicates the possibility of another payer covering the care. This means that the insurance company has determined that there may be another insurance policy in place that should be responsible for the payment of the services rendered. Denial code 22 is used to inform the healthcare provider that they should coordinate benefits with other insurance providers before seeking reimbursement from the current payer.

2. Common Reasons

The most common reasons for denial code 22 are:

1. Multiple Insurance Policies: Denial code 22 often occurs when a patient has multiple insurance policies. If the provider fails to coordinate benefits with all the relevant insurance companies, the claim may be denied under denial code 22.
2. Incomplete or Inaccurate Information: If the provider does not provide complete or accurate information about other insurance coverage, the current payer may deny the claim under denial code 22. It is crucial to ensure that all relevant insurance information is provided to avoid this denial.
3. Failure to Follow Coordination of Benefits Guidelines: Each insurance company has specific guidelines for coordinating benefits. If the provider fails to follow these guidelines, the claim may be denied under denial code 22. It is essential to familiarize yourself with the coordination of benefits requirements of each insurance company to avoid this denial.

3. Next Steps

To resolve denial code 22, follow these next steps:

1. Verify Insurance Information: Double-check the insurance information provided by the patient to ensure its accuracy and completeness. Confirm if there are any other insurance policies that should be coordinated.
2. Coordinate Benefits: Contact all relevant insurance companies to coordinate benefits. Provide them with the necessary information and documentation to determine if they should be the primary payer for the care.
3. Submit Corrected Claim: If it is determined that another insurance company should be responsible for the care, submit a corrected claim to the appropriate payer. Ensure that the claim includes all the necessary information and follows the coordination of benefits guidelines.
4. Follow Up: Monitor the progress of the claim and follow up with the insurance companies to ensure timely processing and payment.

4. How To Avoid It

To avoid denial code 22 in the future, consider the following tips:

1. Collect Comprehensive Insurance Information: Gather complete and accurate insurance information from patients, including details of any other insurance policies they may have.
2. Verify Coverage: Verify the coverage and benefits of all insurance policies before providing care. This will help identify which insurance company should be the primary payer.
3. Follow Coordination of Benefits Guidelines: Familiarize yourself with the coordination of benefits guidelines of each insurance company and ensure that you follow them when submitting claims.
4. Communicate with Patients: Educate patients about the importance of providing complete and accurate insurance information. Encourage them to inform you of any changes in their insurance coverage.

5. Example Cases

Here are two examples of denial code 22:

• Example 1: A patient has primary insurance through their employer and secondary insurance through their spouse’s employer. The provider submits a claim to the primary insurance, but it is denied under denial code 22 because the secondary insurance should be the primary payer.
• Example 2: A patient has Medicare as their primary insurance and a private insurance policy as their secondary insurance. The provider fails to coordinate benefits with the secondary insurance, resulting in a denial under denial code 22.

Source: Claim Adjustment Reason Codes