How To Fix Denial Code 284 | Common Reasons, Next Steps & How To Avoid It

Denial Code 284 means that the precertification/authorization/notification/pre-treatment number provided may be valid, but it does not apply to the billed services. In this article, we will provide a detailed description of denial code 284, 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 284 cases.

2. Description

Denial Code 284 is a Claim Adjustment Reason Code (CARC) that indicates the precertification/authorization/notification/pre-treatment number provided is valid but does not apply to the services billed. This means that the insurance company will not approve payment for the specific services mentioned in the claim, even if the precertification or authorization number is correct. It is essential to ensure that the services being billed align with the approved precertification or authorization to avoid denial code 284.

2. Common Reasons

The most common reasons for denial code 284 are:

1. Service Not Covered: Denial code 284 may occur when the billed services are not covered under the patient’s insurance plan. Even if the precertification or authorization number is valid, the insurance company will deny payment if the services fall outside the coverage guidelines.
2. Incorrect Procedure Codes: If the procedure codes listed in the claim do not match the approved precertification or authorization, denial code 284 may be triggered. It is crucial to ensure that the correct procedure codes are used to align with the approved services.
3. Expired Precertification/Authorization: If the precertification or authorization has expired by the time the claim is submitted, denial code 284 may be issued. It is essential to verify the validity period of the precertification or authorization and submit the claim within the specified timeframe.
4. Mismatched Service Descriptions: Denial code 284 can occur if there is a discrepancy between the services described in the claim and the approved precertification or authorization. It is crucial to accurately document and describe the services being billed to avoid any inconsistencies.
5. Missing or Incomplete Information: If the claim is missing or has incomplete information regarding the precertification or authorization, denial code 284 may be issued. It is important to ensure that all necessary information, including the precertification or authorization number, is included in the claim submission.

3. Next Steps

To resolve denial code 284, follow these next steps:

1. Review the Precertification/Authorization: Carefully review the precertification or authorization documentation to ensure that the services being billed align with the approved services. Check for any discrepancies or mismatches that may have triggered the denial.
2. Verify Coverage: Confirm whether the billed services are covered under the patient’s insurance plan. If the services are not covered, explore alternative options for reimbursement or discuss with the patient about potential out-of-pocket expenses.
3. Update Procedure Codes: If the denial was due to incorrect procedure codes, update the claim with the appropriate codes that match the approved precertification or authorization. Ensure that the codes accurately represent the services provided.
4. Renew Precertification/Authorization: If the precertification or authorization has expired, contact the insurance company to request a renewal. Once renewed, resubmit the claim with the updated precertification or authorization information.
5. Complete Missing Information: If the claim was denied due to missing or incomplete information, ensure that all necessary details, including the precertification or authorization number, are included in the resubmitted claim. Double-check for any other missing information that may have contributed to the denial.
6. Appeal the Denial: If you believe the denial was issued in error or have additional supporting documentation, consider appealing the denial. Provide any relevant documentation that demonstrates the validity of the precertification or authorization and the alignment of the billed services.

4. How To Avoid It

To avoid denial code 284 in the future, consider the following tips:

1. Thoroughly Understand Insurance Coverage: Familiarize yourself with the patient’s insurance coverage, including the specific services that require precertification or authorization. Ensure that you have a clear understanding of the coverage guidelines to avoid billing for services that are not covered.
2. Double-Check Procedure Codes: Always verify that the procedure codes being used in the claim match the approved precertification or authorization. Review the documentation to ensure accuracy and consistency.
3. Monitor Precertification/Authorization Expiration: Keep track of the expiration dates for precertification or authorization. Submit claims within the valid timeframe to avoid denials due to expired documentation.
4. Provide Complete and Accurate Information: Ensure that all necessary information, including the precertification or authorization number, is included in the claim submission. Double-check for any missing or incomplete information that may lead to denials.
5. Regularly Communicate with Insurance Providers: Stay in touch with insurance providers to stay updated on any changes in coverage guidelines or precertification/authorization requirements. Regular communication can help prevent surprises and ensure compliance with insurance policies.

5. Example Cases

Here are two examples of denial code 284:

• Example 1: A provider submits a claim for a surgical procedure that requires precertification. However, the procedure code listed in the claim does not match the approved precertification, resulting in denial code 284.
• Example 2: A patient receives a referral for a specific diagnostic test that requires authorization. The provider submits the claim with the correct authorization number, but the service description in the claim does not align with the approved authorization, leading to denial code 284.

Source: Claim Adjustment Reason Codes