How To Fix Denial Code 276 | Common Reasons, Next Steps & How To Avoid It

Denial Code 276 means that the services being claimed were denied by the prior payer(s) and are not covered by the current payer. In this article, we will provide a detailed description of denial code 276, 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 276 cases.

2. Description

Denial Code 276 is a Claim Adjustment Reason Code (CARC) that indicates the current payer will not cover the services being claimed because they were previously denied by the prior payer(s). This denial typically occurs when the services provided were not deemed medically necessary or did not meet the coverage criteria of the prior payer(s). As a result, the current payer will also deny coverage for these services.

2. Common Reasons

The most common reasons for denial code 276 include:

1. Medical Necessity: The services being claimed may not meet the medical necessity criteria established by the prior payer(s). This could be due to insufficient documentation, lack of supporting evidence, or failure to meet specific guidelines outlined by the prior payer(s).
2. Coverage Criteria: The services may not meet the coverage criteria set by the prior payer(s). This could include limitations on certain procedures, restrictions on the number of allowed visits, or exclusions for specific conditions or treatments.
3. Preauthorization Requirements: The services may require preauthorization from the prior payer(s), and if this step was not completed or the request was denied, the current payer will also deny coverage.
4. Out-of-Network Providers: If the services were provided by an out-of-network provider and the prior payer(s) do not provide coverage for out-of-network services, the current payer will also deny coverage.
5. Incorrect Coding or Documentation: Errors in coding or insufficient documentation can lead to denial code 276. If the services were not accurately coded or the documentation did not adequately support the medical necessity or coverage criteria, the prior payer(s) may have denied the claim, resulting in the current payer also denying coverage.

3. Next Steps

To resolve denial code 276, follow these next steps:

1. Review Denial Explanation: Carefully review the denial explanation provided by the current payer. Understand the specific reasons for the denial and identify which prior payer(s) denied the services.
2. Appeal with Prior Payer(s): If you believe the services were incorrectly denied by the prior payer(s), initiate an appeal process with them. Provide any additional documentation or information that supports the medical necessity or coverage criteria for the services.
3. Coordinate with Current Payer: While appealing with the prior payer(s), communicate with the current payer to inform them about the appeal process and provide updates on the progress. They may require documentation or updates from the prior payer(s) to reconsider the denial.
4. Seek Alternative Coverage: If the appeal with the prior payer(s) is unsuccessful, explore alternative coverage options. This could involve identifying other payers who may provide coverage for the services or exploring financial assistance programs for patients who cannot afford the services out-of-pocket.
5. Update Coding and Documentation: If the denial was due to coding or documentation errors, ensure that the services are accurately coded and well-documented. This will help prevent future denials and improve the chances of successful appeals.

4. How To Avoid It

To avoid denial code 276 in the future, consider the following tips:

1. Verify Coverage Criteria: Before providing services, verify the coverage criteria set by the prior payer(s). Ensure that the services being provided meet their guidelines and requirements.
2. Obtain Preauthorization: If preauthorization is required, make sure to obtain it from the prior payer(s) before providing the services. This will help prevent denials based on lack of preauthorization.
3. Accurate Coding and Documentation: Ensure that all services are accurately coded and well-documented. This includes providing sufficient evidence of medical necessity and meeting the coverage criteria established by the prior payer(s).
4. Network Participation: If possible, ensure that the providers are part of the network established by the prior payer(s). This will help avoid denials based on out-of-network services.
5. Stay Updated: Stay informed about any changes in the coverage criteria or guidelines set by the prior payer(s). Regularly review their policies to ensure compliance and prevent denials.

5. Example Cases

Here are two examples of denial code 276:

• Example 1: A patient undergoes a specialized diagnostic test that requires preauthorization from their previous insurance provider. However, the preauthorization request is denied, resulting in denial code 276 from the current payer.
• Example 2: A provider submits a claim for a procedure that is not covered by the prior payer(s) due to specific coverage limitations. As a result, the current payer also denies coverage under denial code 276.

Source: Claim Adjustment Reason Codes