Denial Code 228 means that a claim has been denied due to the failure of this provider, another provider, or the subscriber to supply requested information to a previous payer for their adjudication. Below you can find the description, common reasons for denial code 228, next steps, how to avoid it, and examples.
2. Description
Denial Code 228 is a Claim Adjustment Reason Code (CARC) that indicates a claim has been denied because the necessary information requested by a previous payer was not provided. This denial typically occurs when the provider, another provider involved in the claim, or the subscriber fails to supply the required information for the previous payer to complete their adjudication process. Without the requested information, the claim cannot be properly processed and is therefore denied.
2. Common Reasons
The most common reasons for denial code 228 are:
- Incomplete Documentation: Denial code 228 often occurs when the necessary documentation or information is missing from the claim submission. This can include medical records, referral forms, prior authorization documentation, or any other supporting documentation required by the previous payer.
- Missing Subscriber Information: If the subscriber fails to provide the necessary information, such as their insurance policy details or identification number, the claim may be denied under code 228. Without this information, the previous payer cannot properly process the claim.
- Lack of Coordination: Denial code 228 can also result from a lack of coordination between providers involved in the claim. If one provider fails to supply the required information to another provider, or if there is miscommunication regarding the necessary documentation, the claim may be denied.
- Failure to Respond to Information Requests: In some cases, the previous payer may request additional information or documentation to complete their adjudication process. If the provider, another provider, or the subscriber fails to respond to these requests in a timely manner, the claim may be denied under code 228.
- Incorrect or Inaccurate Information: Denial code 228 can also occur if the information provided to the previous payer is incorrect or inaccurate. This can include errors in patient demographics, service dates, or any other relevant information required for proper claim processing.
3. Next Steps
To address denial code 228, follow these next steps:
- Review Claim Documentation: Start by reviewing the claim documentation to identify any missing or incomplete information. Determine which specific information was requested by the previous payer and ensure that it is included in the claim submission.
- Communicate with Involved Parties: If the denial was due to a failure of another provider or the subscriber to supply the requested information, reach out to them to request the necessary documentation. Establish clear lines of communication to ensure that all parties involved understand their responsibilities in providing the required information.
- Resubmit the Claim: Once you have gathered all the necessary information, resubmit the claim to the previous payer. Ensure that all requested documentation is included and that the claim is accurately completed. Double-check all information to avoid any errors or inaccuracies that could result in further denials.
- Follow Up with Previous Payer: After resubmitting the claim, follow up with the previous payer to confirm that they have received the necessary information and that the claim is being processed. Stay in communication with them to address any additional requests or concerns they may have.
- Document and Track Communication: Throughout the process, document all communication with the previous payer, providers, and the subscriber. Keep a record of the requested information, any responses or follow-ups, and any other relevant details. This documentation can be valuable in resolving any disputes or issues that may arise.
4. How To Avoid It
To avoid denial code 228 in the future, consider the following steps:
- Ensure Complete Documentation: Make sure that all necessary documentation is included with the claim submission. This includes medical records, referral forms, prior authorization documentation, and any other supporting documentation required by the previous payer.
- Verify Subscriber Information: Double-check that all subscriber information is accurate and up to date. This includes insurance policy details, identification numbers, and any other relevant information required for proper claim processing.
- Coordinate with Involved Providers: Establish clear lines of communication and coordination with other providers involved in the claim. Ensure that all necessary information is shared promptly and accurately to avoid any delays or denials.
- Respond to Information Requests: If the previous payer requests additional information or documentation, respond to these requests in a timely manner. Prioritize communication and provide the requested information as soon as possible to avoid any unnecessary denials.
- Double-Check Information Accuracy: Before submitting the claim, double-check all information for accuracy. Verify patient demographics, service dates, and any other relevant details to minimize the risk of denials due to incorrect or inaccurate information.
5. Example Cases
Below are two examples of denial code 228:
- Example 1: A provider submits a claim for a surgical procedure but fails to include the necessary surgical notes and documentation. The claim is denied under code 228 because the requested information was not provided to the previous payer.
- Example 2: A subscriber fails to provide their updated insurance policy details to their healthcare provider. When the provider submits a claim without this information, it is denied under code 228 as the necessary subscriber information was missing.
