Denial Code 279 means that the services billed were not provided by preferred network providers. This code is used when there are limitations on member network usage, such as using contracted providers who are not part of the member’s ‘narrow’ network. In this article, we will provide a description of denial code 279, 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 279 cases.
2. Description
Denial Code 279 is a Claim Adjustment Reason Code (CARC) that indicates the services billed were not provided by preferred network providers. This code is used when there are limitations on member network usage, specifically when contracted providers who are not part of the member’s ‘narrow’ network are utilized. It signifies that the insurance company will not make payment for the services rendered by these non-preferred providers.
2. Common Reasons
The most common reasons for denial code 279 are:
- Out-of-Network Providers: Denial code 279 often occurs when healthcare services are obtained from providers who are not part of the member’s preferred network. This can happen when patients seek care from specialists or facilities that are not included in their insurance plan’s network.
- Referral Requirements: Some insurance plans require referrals from primary care physicians for certain services or specialists. If a patient seeks care without obtaining the necessary referral, denial code 279 may be triggered.
- Network Changes: Insurance networks can change over time, and providers who were previously in-network may no longer be included. If a patient continues to receive services from these providers without updating their insurance information, denial code 279 may be issued.
- Plan Limitations: Certain insurance plans have restrictions on the types of providers or facilities that are covered. If a patient receives services from a provider or facility that is not included in their plan’s coverage, denial code 279 may be applied.
- Incorrect Provider Information: Errors in provider information, such as incorrect billing addresses or identification numbers, can result in denial code 279. This can occur when the insurance company is unable to verify the provider’s network status due to inaccurate information.
3. Next Steps
To resolve denial code 279, follow these next steps:
- Review Provider Network: Verify the provider’s network status by contacting the insurance company or checking their online provider directory. Ensure that the services were rendered by preferred network providers.
- Appeal the Denial: If the denial was issued in error or there are extenuating circumstances, submit an appeal to the insurance company. Provide documentation supporting the use of non-preferred providers, such as referrals or medical necessity justifications.
- Coordinate with Primary Care Physician: If a referral was required but not obtained, consult with the primary care physician to obtain the necessary referral. This may involve scheduling an appointment or obtaining a retroactive referral if appropriate.
- Negotiate Payment: In some cases, it may be possible to negotiate payment arrangements with the non-preferred provider. This can involve discussing discounted rates or setting up a payment plan to cover the cost of services.
- Update Provider Information: Ensure that accurate provider information is submitted on future claims to avoid denials due to incorrect network status. Double-check billing addresses, identification numbers, and any other relevant provider details.
4. How To Avoid It
To avoid denial code 279 in the future, consider the following tips:
- Verify Network Coverage: Before seeking healthcare services, confirm that the providers or facilities are part of the patient’s insurance plan’s network. This can be done by contacting the insurance company or checking their online provider directory.
- Understand Referral Requirements: Familiarize yourself with the referral requirements of the insurance plan. Ensure that necessary referrals are obtained from primary care physicians before seeking care from specialists or facilities.
- Stay Informed About Network Changes: Keep track of any changes to the insurance plan’s network. Providers who were previously in-network may no longer be covered, so it’s important to update insurance information and seek care from current network providers.
- Review Plan Limitations: Understand the limitations of the insurance plan, such as restrictions on certain providers or facilities. Ensure that services are obtained from covered providers to avoid denials.
- Submit Accurate Provider Information: Double-check the accuracy of provider information when submitting claims. Verify billing addresses, identification numbers, and any other relevant details to prevent denials due to incorrect network status.
5. Example Cases
Here are two examples of denial code 279:
- Example 1: A patient seeks specialized care from a provider who is not part of their insurance plan’s network. As a result, the claim is denied under denial code 279.
- Example 2: A patient undergoes a medical procedure without obtaining the required referral from their primary care physician. The claim is subsequently denied under denial code 279.
