Denial Code 247 means that the deductible for a professional service rendered in an institutional setting and billed on an institutional claim has not been met. Below you can find the description, common reasons for denial code 247, next steps, how to avoid it, and examples.
2. Description
Denial Code 247 is a specific denial code that applies to professional services rendered in an institutional setting and billed on an institutional claim. This code indicates that the patient’s deductible for the service has not been met, resulting in the denial of payment by the insurance company. It is important to note that this denial code is specific to Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
2. Common Reasons
The most common reasons for denial code 247 are:
- Unmet Deductible: The primary reason for denial code 247 is that the patient’s deductible for the professional service rendered in an institutional setting has not been fully satisfied. This means that the patient has not yet paid the required amount out-of-pocket before the insurance company will cover the cost of the service.
- Incorrect Billing: Another reason for denial code 247 could be incorrect billing. If the service was not properly coded or billed on an institutional claim, it may result in the denial of payment due to the mismatch between the service provided and the claim submitted.
- Lack of Documentation: Insufficient or incomplete documentation to support the professional service rendered in an institutional setting can also lead to denial code 247. Without proper documentation, the insurance company may not have enough evidence to determine the necessity and appropriateness of the service, resulting in the denial of payment.
3. Next Steps
You can fix denial code 247 as follows:
- Verify Deductible Status: First, verify the patient’s current deductible status for the professional service rendered in an institutional setting. Determine if the deductible has been met or if there is still an outstanding amount that needs to be paid by the patient.
- Review Billing Information: Check the billing information to ensure that the professional service was correctly coded and billed on an institutional claim. Any errors or discrepancies in the billing information should be corrected before resubmitting the claim.
- Provide Additional Documentation: If the denial was due to lack of documentation, gather and provide any additional documentation that supports the necessity and appropriateness of the professional service rendered in an institutional setting. This may include medical records, test results, or other relevant documentation.
- Resubmit the Claim: Once you have verified the deductible status, reviewed the billing information, and provided any necessary additional documentation, resubmit the claim to the insurance company for reconsideration. Make sure to include a clear explanation of why the denial should be overturned.
- Follow Up with the Insurance Company: If the denial is not overturned after resubmitting the claim, follow up with the insurance company to understand the specific reasons for the denial and to explore any possible avenues for appeal or resolution.
4. How To Avoid It
You can prevent denial code 247 in the future as follows:
- Verify Deductible Coverage: Before providing any professional service in an institutional setting, verify the patient’s insurance coverage and deductible status. Make sure the patient is aware of their deductible obligations and any outstanding amounts that need to be paid.
- Ensure Accurate Billing: Double-check the coding and billing information to ensure that the professional service is correctly coded and billed on an institutional claim. Any errors or discrepancies should be corrected before submitting the claim.
- Document Necessity and Appropriateness: Thoroughly document the necessity and appropriateness of the professional service rendered in an institutional setting. Include all relevant medical records, test results, and other supporting documentation to provide a clear and comprehensive picture of the service provided.
- Communicate with the Insurance Company: Maintain open lines of communication with the insurance company to address any questions or concerns regarding the professional service rendered in an institutional setting. This can help prevent misunderstandings and ensure that the claim is processed correctly.
5. Example Cases
Below are two examples of denial code 247:
- Example 1: A patient undergoes a surgical procedure in a hospital setting and the professional service is billed on an institutional claim. However, the patient’s deductible for this service has not been met, resulting in denial code 247.
- Example 2: A physician provides a consultation in an outpatient clinic that is part of an institutional setting. The service is billed on an institutional claim, but the patient’s deductible has not been fully satisfied, leading to denial code 247.
