Denial Code 260 means that a claim has been processed under the Medicaid ACA Enhanced Fee Schedule. Below you can find the description, common reasons for denial code 260, next steps, how to avoid it, and examples.
2. Description
Denial Code 260 is a specific code that indicates a claim has been processed under the Medicaid ACA Enhanced Fee Schedule. This means that the payment for the billed service has been determined based on the fee schedule set forth by the Medicaid program under the Affordable Care Act (ACA). The fee schedule outlines the maximum allowable reimbursement rates for specific services provided to Medicaid beneficiaries.
2. Common Reasons
The most common reasons for denial code 260 are:
- Ineligible Service: Denial code 260 may occur if the service billed is not eligible for reimbursement under the Medicaid ACA Enhanced Fee Schedule. This could be due to the service not being covered by Medicaid or not meeting the specific criteria outlined in the fee schedule.
- Incorrect Coding: If the service is coded incorrectly on the claim, it may result in denial code 260. This could include using an incorrect procedure code or failing to provide sufficient documentation to support the service being billed.
- Lack of Prior Authorization: Some services require prior authorization from Medicaid before they can be reimbursed. If the provider fails to obtain the necessary authorization, the claim may be denied under code 260.
- Exceeding Maximum Allowable Reimbursement: The Medicaid ACA Enhanced Fee Schedule sets maximum reimbursement rates for each service. If the billed amount exceeds the maximum allowable reimbursement, the claim may be denied under code 260.
- Provider Enrollment Issues: Denial code 260 may also occur if there are issues with the provider’s enrollment in the Medicaid program. This could include expired or inactive provider credentials, incorrect billing information, or failure to meet other program requirements.
3. Next Steps
You can address denial code 260 by taking the following steps:
- Review the Fee Schedule: Familiarize yourself with the Medicaid ACA Enhanced Fee Schedule to ensure that the service billed is eligible for reimbursement and that the billed amount does not exceed the maximum allowable reimbursement.
- Verify Coding Accuracy: Double-check the coding on the claim to ensure that the correct procedure codes are used and that all necessary documentation is included to support the service being billed.
- Obtain Prior Authorization: If the service requires prior authorization, make sure to obtain the necessary approval from Medicaid before submitting the claim.
- Address Provider Enrollment Issues: If the denial is due to provider enrollment issues, work with the Medicaid program to resolve any credentialing or billing information discrepancies. Ensure that all provider information is up to date and that you meet all program requirements.
- Appeal if Necessary: If you believe the denial was in error or have additional documentation to support the claim, consider appealing the denial. Follow the appeals process outlined by the Medicaid program to challenge the denial and provide any necessary documentation.
4. How To Avoid It
To avoid denial code 260 in the future, consider the following steps:
- Stay Informed: Keep up to date with the Medicaid ACA Enhanced Fee Schedule and any changes or updates to the reimbursement rates or covered services.
- Ensure Accurate Coding: Train your coding staff to accurately assign procedure codes and provide thorough documentation to support the services being billed.
- Obtain Prior Authorization: Familiarize yourself with the services that require prior authorization and ensure that the necessary approvals are obtained before submitting claims.
- Maintain Provider Enrollment: Regularly review and update your provider enrollment information to ensure that it is accurate and up to date. Monitor any expiration dates or requirements to maintain active enrollment in the Medicaid program.
5. Example Cases
Below are two examples of denial code 260:
- Example 1: A provider submits a claim for a service that is not covered under the Medicaid ACA Enhanced Fee Schedule. The claim is denied under code 260, indicating that the service is not eligible for reimbursement.
- Example 2: A provider bills for a service that requires prior authorization, but fails to obtain the necessary approval from Medicaid. The claim is denied under code 260 due to the lack of prior authorization.
