How To Fix Denial Code 275 | Common Reasons, Next Steps & How To Avoid It

Denial Code 275 means that the patient’s responsibility for deductibles, coinsurance, or copayments from a prior payer has not been covered. This denial code is used in conjunction with Group Code PR. In this article, we will provide a description of denial code 275, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code 275 cases.

2. Description

Denial Code 275 is a Claim Adjustment Reason Code (CARC) that indicates the patient’s financial responsibility for deductibles, coinsurance, or copayments from a previous payer has not been covered. This code is typically used when the primary insurance has not fully paid the patient’s portion, and the remaining balance is being passed on to the secondary payer or the patient themselves. It is important to address this denial code to ensure proper reimbursement and prevent financial burden on the patient.

2. Common Reasons

The most common reasons for denial code 275 are:

1. Incomplete Coordination of Benefits: Denial code 275 often occurs when there is a lack of coordination between primary and secondary insurance providers. If the primary payer does not accurately communicate the patient’s financial responsibility, the secondary payer may deny the claim, resulting in denial code 275.
2. Unmet Deductibles: If the patient has not met their deductible with the primary payer, denial code 275 may be triggered. The secondary payer will not cover the patient’s financial responsibility until the deductible has been satisfied.
3. Incorrect Billing Information: Errors in billing information, such as incorrect patient identifiers or service codes, can lead to denial code 275. It is crucial to ensure accurate and complete information is provided to avoid claim denials.
4. Out-of-Network Providers: If the patient received services from an out-of-network provider, the primary payer may not cover the full amount, resulting in denial code 275. It is important to verify network coverage and inform patients of potential out-of-pocket expenses.

3. Next Steps

To resolve denial code 275, follow these next steps:

1. Review the Explanation of Benefits (EOB): Obtain the EOB from the primary payer to understand the patient’s financial responsibility and the reason for denial. This will help identify any discrepancies or issues that need to be addressed.
2. Contact the Primary Payer: Reach out to the primary payer to clarify any misunderstandings or errors in their determination of the patient’s financial responsibility. Provide any necessary documentation or information to support your case.
3. Appeal the Denial: If the primary payer’s determination is incorrect, submit an appeal with supporting documentation to challenge the denial. Clearly explain why the patient’s financial responsibility should be covered by the primary payer.
4. Inform the Secondary Payer: If the primary payer confirms that the patient’s financial responsibility has not been covered, inform the secondary payer about the denial and provide them with the necessary documentation. They may require additional information to process the claim correctly.
5. Update Patient Records: Make sure to update the patient’s records with the correct financial responsibility information to avoid future denials or confusion.

4. How To Avoid It

To prevent denial code 275 in the future, consider the following tips:

1. Verify Coordination of Benefits: Ensure that primary and secondary insurance providers have accurate and up-to-date information regarding the patient’s coverage and financial responsibility.
2. Educate Patients: Clearly communicate to patients their financial responsibilities, including deductibles, coinsurance, and copayments. Provide them with information about their insurance coverage and potential out-of-pocket expenses.
3. Double-Check Billing Information: Review all billing information for accuracy before submitting claims. Verify patient identifiers, service codes, and other relevant details to minimize errors that could lead to denials.
4. Stay In-Network: Encourage patients to seek services from in-network providers to ensure maximum coverage and minimize the risk of denials.

5. Example Cases

Here are two examples of denial code 275:

• Example 1: A patient undergoes a surgical procedure covered by their primary insurance. However, the primary payer determines that the patient has a deductible that has not been met. As a result, the secondary payer denies the claim under denial code 275, stating that the patient’s financial responsibility has not been covered.
• Example 2: A patient visits an out-of-network specialist for a consultation. The primary payer covers a portion of the expenses, but the patient’s financial responsibility is not fully met. The secondary payer denies the claim under denial code 275, indicating that the patient’s responsibility from the primary payer has not been covered.

Source: Claim Adjustment Reason Codes