Denial Code 238 means that a claim spans eligible and ineligible periods of coverage, resulting in a reduction for the ineligible period. This denial code is used in conjunction with Group Code PR. In this article, we will provide a detailed description of denial code 238, common reasons for its occurrence, next steps to resolve it, tips on how to avoid it in the future, and examples to illustrate its application.
2. Description
Denial Code 238 is a specific Claim Adjustment Reason Code (CARC) that indicates a claim has been denied because it covers both eligible and ineligible periods of coverage. This results in a reduction in payment for the portion of the claim that falls within the ineligible period. It is important to note that this denial code is used in conjunction with Group Code PR, which signifies that the patient responsibility is being reduced.
2. Common Reasons
The most common reasons for denial code 238 are:
- Termination of Coverage: Denial code 238 often occurs when a patient’s insurance coverage is terminated during the course of treatment. If a claim is submitted for services rendered after the termination date, the portion of the claim falling within the ineligible period will be denied.
- Lapse in Coverage: Another common reason for denial code 238 is when there is a lapse in coverage. If a patient’s insurance coverage is not continuous and there is a gap between the end of one policy and the start of another, any claims submitted for services during the gap period will be denied.
- Incorrect Effective Dates: Denial code 238 may also occur due to errors in the effective dates of coverage. If the dates provided on the claim do not align with the patient’s actual coverage period, the claim may be denied for the portion falling outside the eligible period.
- Policy Exclusions: Some insurance policies have specific exclusions for certain services or treatments. If a claim includes services that are excluded under the patient’s policy, denial code 238 may be applied to reduce payment for the ineligible portion of the claim.
3. Next Steps
If you encounter denial code 238, follow these next steps to resolve the issue:
- Review Claim Details: Carefully review the details of the claim to identify the specific dates of service and the corresponding coverage periods. Ensure that the claim accurately reflects the patient’s insurance coverage during the time the services were rendered.
- Verify Termination or Lapse in Coverage: If the denial is due to termination or a lapse in coverage, confirm the dates of termination or the gap in coverage. This information will be crucial in determining the portion of the claim that falls within the ineligible period.
- Calculate Reduction Amount: Calculate the reduction amount based on the portion of the claim that is ineligible for payment. This will help determine the adjusted payment that should be expected for the claim.
- Adjust Patient Responsibility: Update the patient’s responsibility to reflect the reduced payment amount. This may involve recalculating any co-pays, deductibles, or coinsurance amounts that the patient is responsible for.
- Resubmit or Appeal: Depending on the circumstances, you may need to resubmit the claim with the appropriate adjustments or file an appeal if you believe the denial was in error. Provide any necessary documentation to support your case, such as proof of coverage or corrected effective dates.
- Communicate with the Patient: Keep the patient informed about the status of their claim and any adjustments made. Explain the reasons for the denial and the resulting reduction in payment. Address any questions or concerns they may have regarding their financial responsibility.
4. How To Avoid It
To avoid denial code 238 in the future, consider the following tips:
- Verify Coverage Periods: Before providing any services, verify the patient’s insurance coverage and ensure that it aligns with the dates of service. This will help prevent claims from spanning both eligible and ineligible periods.
- Stay Up-to-Date on Policy Changes: Stay informed about any changes or updates to insurance policies, including coverage periods and exclusions. Regularly review policy documents and communicate with insurance providers to ensure accurate billing.
- Double-Check Effective Dates: When submitting claims, double-check the effective dates of coverage to ensure accuracy. Confirm that the dates align with the patient’s actual coverage period to avoid denials due to incorrect information.
- Educate Staff: Provide training to your billing and administrative staff on the importance of verifying coverage periods and understanding policy exclusions. Ensure they are equipped with the knowledge to accurately process claims and avoid denials.
5. Example Cases
Here are two examples illustrating the application of denial code 238:
- Example 1: A patient undergoes a surgical procedure on January 15th, but their insurance coverage terminates on January 31st. The claim for the procedure is submitted, but denial code 238 is applied to reduce payment for the portion falling within the ineligible period (January 16th-31st).
- Example 2: A patient’s insurance coverage lapses for two months due to a change in employment. During this period, they receive medical services. When the claims are submitted, denial code 238 is applied to reduce payment for the portion falling within the gap in coverage.
Denial code 238 can be challenging to navigate, but by understanding the common reasons for its occurrence, following the appropriate next steps, implementing preventive measures, and learning from example cases, healthcare providers can effectively address and avoid this denial code in their billing processes.
