Denial Code 258 means that a claim or service is not covered when the patient is in custody or incarcerated. In such cases, the applicable federal, state, or local authority may be responsible for covering the claim or service. Below you can find a detailed description of denial code 258, common reasons for its occurrence, next steps to resolve it, tips on how to avoid it in the future, and examples of denial code 258 cases.
2. Description
Denial Code 258 is a specific claim adjustment reason code (CARC) that indicates that the claim or service is not covered when the patient is in custody or incarcerated. This means that the insurance company will not provide payment for the billed service, as it is the responsibility of the applicable federal, state, or local authority to cover the claim or service. Denial code 258 is applicable from November 1, 2013.
2. Common Reasons
The most common reasons for denial code 258 are:
- Patient Incarceration: Denial code 258 is triggered when the patient is in custody or incarcerated. Insurance companies typically do not cover healthcare services for individuals who are in the custody of authorities, as their medical needs are the responsibility of the applicable authority.
- Applicable Authority Coverage: The denial may occur if the applicable federal, state, or local authority responsible for the patient’s custody or incarceration is expected to provide coverage for the claimed service. In such cases, the insurance company denies the claim, as it is not their responsibility to cover the cost.
- Lack of Coordination: Denial code 258 may also result from a lack of coordination between the healthcare provider, the insurance company, and the applicable authority. If the provider fails to communicate the patient’s custody or incarceration status to the insurance company, the claim may be submitted incorrectly, leading to denial.
3. Next Steps
To resolve denial code 258, follow these steps:
- Verify Patient’s Custody/Incarceration Status: Confirm whether the patient is in custody or incarcerated. This information can be obtained from the patient or their legal representative, or by contacting the applicable authority responsible for their custody.
- Identify Applicable Authority: Determine the specific federal, state, or local authority responsible for the patient’s custody or incarceration. This information is crucial in understanding who should be covering the claimed service.
- Contact Applicable Authority: Reach out to the identified authority to inquire about their coverage policies for healthcare services provided to individuals in custody or incarcerated. Understand the process and requirements for submitting claims to the authority for reimbursement.
- Submit Claim to Applicable Authority: If the applicable authority is responsible for covering the claimed service, follow their guidelines for claim submission. Ensure that all necessary documentation and information are included to support the claim.
- Appeal or Seek Alternative Coverage: If the applicable authority denies the claim or does not provide coverage, you may consider appealing the decision or exploring alternative coverage options. This could involve engaging with legal representatives or seeking assistance from advocacy organizations specializing in healthcare coverage for incarcerated individuals.
4. How To Avoid It
To avoid denial code 258 in the future, consider the following:
- Verify Custody/Incarceration Status: Before providing healthcare services, verify the patient’s custody or incarceration status. This can be done through proper documentation and communication with the patient or their legal representative.
- Coordinate with Applicable Authority: Establish a process for coordinating with the applicable authority responsible for the patient’s custody or incarceration. This can help ensure that the authority is aware of the healthcare services being provided and can facilitate the necessary coverage or reimbursement.
- Educate Staff: Train your billing and administrative staff on the specific requirements and processes related to healthcare services for individuals in custody or incarcerated. This will help prevent incorrect claim submissions and subsequent denials.
5. Example Cases
Here are two examples of denial code 258:
- Example 1: A healthcare provider submits a claim for medical treatment provided to a patient who is currently in custody. The insurance company denies the claim under denial code 258, as the applicable authority responsible for the patient’s custody is expected to cover the cost of the service.
- Example 2: In another scenario, a provider fails to communicate the patient’s incarceration status to the insurance company. As a result, the claim is submitted incorrectly, leading to denial under denial code 258.
