How To Fix Denial Code 237 | Common Reasons, Next Steps & How To Avoid It

Denial Code 237 means that a claim has been denied due to a legislated or regulatory penalty. This denial code requires at least one Remark Code to be provided, which can be either the NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an ALERT. In this article, we will explore the description of Denial Code 237, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples of denial cases.

2. Description

Denial Code 237 is a specific denial code that indicates a claim has been denied due to a legislated or regulatory penalty. This means that the claim does not meet the requirements set forth by the governing laws or regulations. In order to provide more information about the denial, at least one Remark Code must be provided. This Remark Code can be either the NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an ALERT.

2. Common Reasons

The common reasons for Denial Code 237 can vary depending on the specific legislated or regulatory requirements that were not met. Some possible reasons for this denial code may include:

1. Missing or incomplete documentation: Claims may be denied if the required documentation to support the services rendered is missing or incomplete. This could include medical records, authorization forms, or other necessary documentation.
2. Non-compliance with coding guidelines: If the coding used on the claim does not adhere to the specific coding guidelines set forth by the governing bodies, the claim may be denied under Denial Code 237.
3. Failure to meet eligibility criteria: Claims may be denied if the patient does not meet the eligibility criteria for the services rendered. This could include factors such as age, medical necessity, or prior authorization requirements.
4. Incorrect billing practices: If the claim is not billed correctly according to the legislated or regulatory requirements, it may be denied under Denial Code 237. This could include incorrect billing codes, modifiers, or other billing errors.

3. Next Steps

If you receive a denial with Code 237, the following steps can help you resolve the issue:

1. Review the denial letter: Carefully review the denial letter or explanation of benefits (EOB) to understand the specific reason for the denial. Look for any Remark Codes provided that can offer more insight into the legislated or regulatory penalty.
2. Address the specific issue: Once you have identified the specific reason for the denial, take the necessary steps to address the issue. This may involve gathering additional documentation, correcting coding errors, or ensuring compliance with eligibility criteria.
3. Submit an appeal if necessary: If you believe the denial was made in error or have additional information to support the claim, you can submit an appeal. Follow the appeals process outlined by the insurance company or relevant governing body.
4. Seek guidance if needed: If you are unsure about how to address the denial or navigate the appeals process, consider seeking guidance from a billing specialist, coding expert, or professional organization that can provide assistance.

4. How To Avoid It

To avoid Denial Code 237 in the future, consider the following strategies:

1. Stay updated on legislated and regulatory requirements: Regularly review and stay informed about any changes or updates to the legislated and regulatory requirements that impact your billing and coding practices. This can help ensure compliance and reduce the risk of denials.
2. Verify eligibility and coverage: Before providing services, verify the patient’s eligibility and coverage to ensure they meet the necessary criteria. This includes checking for any specific requirements or authorizations that may be needed.
3. Ensure accurate and complete documentation: Maintain accurate and complete documentation for all services rendered. This includes medical records, authorization forms, and any other supporting documentation that may be required.
4. Adhere to coding guidelines: Follow the coding guidelines set forth by the governing bodies to ensure accurate and compliant coding. Regularly train and educate staff on coding updates and best practices.
5. Double-check billing accuracy: Before submitting claims, double-check the accuracy of the billing information, including codes, modifiers, and other billing details. This can help prevent errors that may lead to denials.

5. Example Cases

Here are two examples of denial cases with Code 237:

• Example 1: A healthcare provider submits a claim for a procedure that requires prior authorization. However, the claim is denied under Denial Code 237 because the necessary authorization was not obtained before the service was rendered.
• Example 2: A billing department mistakenly uses an outdated coding guideline for a specific service. As a result, the claim is denied under Denial Code 237 for non-compliance with the current legislated or regulatory requirements.

By understanding the description, common reasons, next steps, and preventive measures for Denial Code 237, healthcare providers can effectively address and avoid this denial code, ensuring smoother claims processing and reimbursement.

Source: Claim Adjustment Reason Codes