How To Fix Denial Code 222 | Common Reasons, Next Steps & How To Avoid It

Denial Code 222 means that a claim has been denied because it exceeds the contracted maximum number of hours/days/units by this provider for this period. This denial code is not patient specific and can occur when the services billed exceed the agreed-upon limits set by the provider’s contract with the insurance company. In this article, we will explore the description of denial code 222, 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 222 is a specific Claim Adjustment Reason Code (CARC) that indicates a claim has been denied because the services provided exceed the contracted maximum number of hours, days, or units agreed upon between the provider and the insurance company. This denial code is not patient specific, meaning it applies to all patients whose claims exceed the contracted limits. The information regarding the specific limits can be found in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.

2. Common Reasons

The most common reasons for denial code 222 are:

1. Contractual Agreement: Denial code 222 often occurs when the provider has a contractual agreement with the insurance company that sets limits on the number of hours, days, or units that can be billed for a specific period. If the services provided exceed these agreed-upon limits, the claim will be denied under code 222.
2. Incorrect Billing: In some cases, denial code 222 may occur due to billing errors. Providers may mistakenly bill for more hours, days, or units than allowed under their contract, leading to denials. It is crucial for providers to accurately track and document the services provided to ensure compliance with the contracted limits.
3. Lack of Prior Authorization: Certain services may require prior authorization from the insurance company before they can be billed. If a provider fails to obtain the necessary authorization or exceeds the authorized limits, the claim may be denied under code 222.
4. Out-of-Network Services: Denial code 222 can also occur when a provider renders services that are out-of-network or not covered by the patient’s insurance plan. In such cases, the claim will be denied as it exceeds the contracted limits for out-of-network services.

3. Next Steps

To resolve denial code 222, the following steps can be taken:

1. Review Contractual Agreement: First, review the provider’s contractual agreement with the insurance company to understand the specific limits on the number of hours, days, or units that can be billed. Ensure that the services provided do not exceed these limits.
2. Appeal or Correct Billing Errors: If the denial was due to billing errors, such as incorrect documentation or coding, correct the errors and resubmit the claim. Alternatively, if you believe the denial was in error, you can appeal the decision by providing additional documentation or evidence to support the claim.
3. Obtain Prior Authorization: If the denial was due to a lack of prior authorization, work with the insurance company to obtain the necessary authorization for the services provided. Once obtained, resubmit the claim with the proper authorization documentation.
4. Verify Network Coverage: If the denial was due to out-of-network services, verify the patient’s insurance coverage and ensure that the services provided are within the network. If necessary, refer the patient to an in-network provider or explore other options for coverage.

4. How To Avoid It

To avoid denial code 222 in the future, consider the following strategies:

1. Understand Contractual Limits: Familiarize yourself with the contractual agreement between your practice and the insurance company. Ensure that you are aware of the specific limits on the number of hours, days, or units that can be billed for each period.
2. Accurate Documentation and Coding: Maintain accurate documentation of the services provided, including the number of hours, days, or units. Ensure that the services are coded correctly to reflect the actual services rendered.
3. Prior Authorization: For services that require prior authorization, obtain the necessary authorization from the insurance company before providing the services. This will help prevent denials due to a lack of authorization.
4. Network Coverage: Verify the patient’s insurance coverage and ensure that the services provided are within the network. If necessary, refer the patient to an in-network provider to avoid denials for out-of-network services.

5. Example Cases

Here are two examples of denial code 222:

• Example 1: A provider submits a claim for 10 physical therapy sessions, but their contractual agreement with the insurance company only allows for a maximum of 8 sessions per month. The claim is denied under code 222 as it exceeds the contracted maximum number of units.
• Example 2: A provider performs a surgical procedure that requires prior authorization from the insurance company. However, the provider fails to obtain the necessary authorization before performing the procedure. As a result, the claim is denied under code 222.

Source: Claim Adjustment Reason Codes