How To Fix Denial Code 248 | Common Reasons, Next Steps & How To Avoid It

Denial Code 248 means that coinsurance for a professional service rendered in an institutional setting and billed on an institutional claim has been denied. Below you can find the description, common reasons for denial code 248, next steps, how to avoid it, and examples.

2. Description

Denial Code 248 is a specific denial code that pertains to coinsurance for professional services rendered in an institutional setting and billed on an institutional claim. This denial code is typically used for Medicare bundled payment purposes under the Patient Protection and Affordable Care Act (PPACA). It indicates that the insurance company will not make the payment for the coinsurance portion of the billed service due to the specific circumstances surrounding the claim.

2. Common Reasons

The most common reasons for denial code 248 are:

1. Incorrect Billing: One common reason for denial code 248 is incorrect billing. This could include billing a professional service as an institutional service or billing an institutional claim for a professional service. It is important to ensure that the correct codes and billing procedures are followed to avoid this denial code.
2. Non-Compliance with Medicare Bundled Payment Rules: Denial code 248 may also occur if the claim does not comply with the Medicare bundled payment rules. This could include not meeting the specific requirements for billing professional services in an institutional setting or not following the guidelines set forth by the PPACA.
3. Lack of Documentation: Insufficient or incomplete documentation can also lead to denial code 248. It is essential to provide all necessary documentation to support the claim and ensure that it meets the requirements for billing professional services in an institutional setting.

3. Next Steps

You can fix denial code 248 as follows:

1. Review the Claim: Start by reviewing the claim that was denied under code 248. Check for any errors or discrepancies in the billing and ensure that the claim was submitted correctly.
2. Verify Compliance: If the claim was denied due to non-compliance with Medicare bundled payment rules, review the specific requirements and guidelines set forth by the PPACA. Make sure that the claim meets all the necessary criteria for billing professional services in an institutional setting.
3. Provide Additional Documentation: If the denial was due to lack of documentation, gather any additional documentation that may be required to support the claim. This could include medical records, treatment plans, or any other relevant information that demonstrates the necessity of the professional service in an institutional setting.
4. Resubmit the Claim: Once you have reviewed the claim, verified compliance, and provided any necessary additional documentation, resubmit the claim for reconsideration. Make sure to include a cover letter explaining the steps taken to address the denial and provide any supporting documentation.
5. Follow Up: After resubmitting the claim, follow up with the insurance company to ensure that it is being processed correctly. If there are any further issues or questions, be prepared to provide additional information or clarification as needed.

4. How To Avoid It

To avoid denial code 248 in the future, consider the following:

1. Proper Coding and Billing: Ensure that professional services rendered in an institutional setting are billed correctly using the appropriate codes and procedures. Double-check the claim before submission to avoid any errors or discrepancies.
2. Compliance with Medicare Bundled Payment Rules: Familiarize yourself with the specific requirements and guidelines for billing professional services in an institutional setting under the Medicare bundled payment rules. Stay up to date with any changes or updates to these rules to ensure compliance.
3. Thorough Documentation: Maintain thorough and accurate documentation for all professional services rendered in an institutional setting. This includes medical records, treatment plans, and any other relevant information that supports the necessity of the service.
4. Regular Training and Education: Provide regular training and education to your billing and administrative staff to ensure they are knowledgeable about the specific requirements and guidelines for billing professional services in an institutional setting. This will help prevent errors and ensure compliance.

5. Example Cases

Below are two examples of denial code 248:

• Example 1: A healthcare provider bills a professional service as an institutional service on an institutional claim, resulting in denial code 248. The claim is denied because it does not meet the specific requirements for billing professional services in an institutional setting.
• Example 2: A provider fails to provide sufficient documentation to support the necessity of a professional service rendered in an institutional setting. The claim is denied under code 248 due to the lack of documentation.

Source: Claim Adjustment Reason Codes