Denial Code 226 means that the information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. This denial code requires at least one Remark Code to be provided, which may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. In this article, we will explore the description, common reasons for denial code 226, next steps to resolve it, how to avoid it in the future, and provide example cases.
2. Description
Denial Code 226 is a specific denial code that indicates that the information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. This means that the insurance company requires additional information or documentation to process the claim properly. Without the necessary information, the claim cannot be processed, resulting in denial.
2. Common Reasons
The most common reasons for denial code 226 are:
- Missing Documentation: One of the main reasons for denial code 226 is the absence of required documentation. This could include medical records, invoices, or other supporting documents that are necessary for the insurance company to evaluate the claim.
- Timely Submission: Another common reason for denial code 226 is the failure to submit the requested information within the specified timeframe. Insurance companies often have deadlines for submitting additional documentation, and if the provider fails to meet these deadlines, the claim may be denied.
- Incomplete Information: Denial code 226 can also occur if the submitted information is incomplete or insufficient. This could include missing or incomplete patient information, incorrect coding, or incomplete medical records.
- Lack of Explanation: Sometimes, the insurance company may request additional explanation or clarification regarding the services provided. If the provider fails to provide a satisfactory explanation, the claim may be denied under code 226.
3. Next Steps
To resolve denial code 226, follow these next steps:
- Review Denial Letter: Carefully review the denial letter received from the insurance company. The letter should specify the exact information or documentation that is required to process the claim.
- Gather Required Information: Collect all the necessary information and documentation as requested in the denial letter. This may include medical records, invoices, or any other supporting documents.
- Submit Additional Documentation: Once you have gathered the required information, submit it to the insurance company within the specified timeframe. Ensure that all the requested information is included and clearly labeled.
- Follow Up: After submitting the additional documentation, follow up with the insurance company to confirm receipt and ensure that the claim is being reevaluated. Keep track of any reference numbers or communication regarding the claim.
- Appeal if Necessary: If the claim is still denied after submitting the requested information, you may need to consider filing an appeal. Follow the insurance company’s appeal process and provide any additional information or documentation that supports the validity of the claim.
4. How To Avoid It
To avoid denial code 226 in the future, consider the following steps:
- Thorough Documentation: Ensure that all necessary documentation is complete, accurate, and up-to-date. This includes medical records, invoices, and any other supporting documents that may be required for claim processing.
- Timely Submission: Adhere to the insurance company’s deadlines for submitting claims and any requested additional information. Timely submission can help prevent denials due to missing or late documentation.
- Clear Communication: Maintain open lines of communication with the insurance company and promptly respond to any requests for additional information or clarification. Clear and concise communication can help expedite the claim processing.
- Double-Check Information: Before submitting a claim, double-check all patient information, coding, and documentation for accuracy and completeness. This can help prevent denials due to incomplete or incorrect information.
5. Example Cases
Below are two examples of denial code 226:
- Example 1: A provider submits a claim for a surgical procedure but fails to include the necessary operative report. The claim is denied under code 226, as the insurance company requires the operative report to evaluate the claim.
- Example 2: A provider submits a claim for physical therapy sessions but does not include the progress notes or treatment plan. The claim is denied under code 226, as the insurance company requires this documentation to assess the medical necessity of the services.
