Denial Code 225 means that a claim has been denied due to a penalty or interest payment by the payer. This denial code is only used for plan to plan encounter reporting within the 837. In this article, we will provide a description of denial code 225, 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 225 cases.
2. Description
Denial Code 225 is a specific denial code used for plan to plan encounter reporting within the 837. It indicates that the claim has been denied due to a penalty or interest payment imposed by the payer. This denial code is typically used when there are discrepancies or non-compliance issues related to the encounter reporting between different healthcare plans.
2. Common Reasons
The most common reasons for denial code 225 are:
- Non-compliance with Encounter Reporting Requirements: Denial code 225 may occur when the encounter reporting between different healthcare plans does not meet the required standards or guidelines. This could include missing or incomplete information, incorrect coding, or failure to submit the necessary documentation.
- Failure to Meet Timely Filing Deadlines: Payers may impose penalties or interest payments if the claim is not submitted within the specified timeframe. Denial code 225 can be triggered if the claim is submitted after the deadline, resulting in the denial of payment.
- Discrepancies in Plan-to-Plan Coordination: Denial code 225 may occur when there are discrepancies or errors in the coordination of benefits between different healthcare plans. This could include incorrect information about the primary payer, coverage limitations, or failure to obtain necessary authorizations.
- Non-Compliance with Plan Requirements: Some healthcare plans may have specific requirements or conditions that must be met for the claim to be reimbursed. If these requirements are not fulfilled, denial code 225 may be applied.
3. Next Steps
To resolve denial code 225, follow these next steps:
- Review Encounter Reporting: Carefully review the encounter reporting between different healthcare plans to identify any discrepancies or non-compliance issues. Ensure that all required information is included and accurately documented.
- Communicate with Payer: Contact the payer to discuss the specific reasons for the denial and seek clarification on any unclear requirements or guidelines. Obtain any necessary documentation or instructions to address the issues identified.
- Correct and Resubmit the Claim: Make the necessary corrections to the encounter reporting or any other identified issues. Ensure that all required information is included and accurately documented. Resubmit the claim to the payer within the specified timeframe.
- Follow Up with Payer: Follow up with the payer to confirm receipt of the corrected claim and to ensure that it is being processed accordingly. Address any additional questions or concerns raised by the payer promptly.
- Appeal if Necessary: If the denial is not resolved through the above steps, consider filing an appeal with the payer. Provide any additional supporting documentation or evidence to support the claim’s validity and compliance with the required standards.
4. How To Avoid It
To avoid denial code 225 in the future, consider the following tips:
- Understand Encounter Reporting Requirements: Familiarize yourself with the encounter reporting requirements of different healthcare plans. Ensure that you have a clear understanding of the necessary information, coding guidelines, and documentation requirements.
- Submit Claims Timely: Adhere to the specified filing deadlines and submit claims within the required timeframe. Establish efficient processes and systems to ensure timely submission of claims.
- Coordinate Benefits Accurately: Ensure accurate coordination of benefits between different healthcare plans. Verify primary payer information, coverage limitations, and obtain necessary authorizations as required.
- Comply with Plan Requirements: Familiarize yourself with the specific requirements of each healthcare plan and ensure compliance. This may include obtaining necessary referrals, authorizations, or meeting specific documentation requirements.
5. Example Cases
Below are two examples of denial code 225:
- Example 1: A healthcare provider submits a claim for an encounter between two different healthcare plans. However, the encounter reporting does not meet the required standards, resulting in denial code 225 and the imposition of a penalty by the payer.
- Example 2: A claim is submitted after the specified filing deadline, leading to denial code 225 and the imposition of an interest payment by the payer.
