Denial Code 287 (CARC) means that a claim has been denied because the referral exceeded the allowed limit. Below you can find the description, common reasons for denial code 287, next steps, how to avoid it, and examples.
2. Description
Denial Code 287 is a Claim Adjustment Reason Code (CARC) and is described as ‘Referral Exceeded’. This indicates that the insurance company has denied the claim because the number of referrals for the specific service or treatment has exceeded the allowed limit. In simpler terms, the claim is not payable because the patient has already reached the maximum number of referrals for that particular service.
2. Common Reasons
The most common reasons for denial code 287 are:
- Exceeded Referral Limit: Denial code 287 occurs when the patient has already utilized the maximum number of referrals allowed for a specific service or treatment. Insurance plans often have limitations on the number of times a patient can be referred for certain procedures or specialist visits within a given time period. If the referral limit has been exceeded, the claim will be denied.
- Outdated or Invalid Referral: Sometimes, denials under code 287 can occur if the referral provided by the primary care physician is outdated or invalid. Insurance companies require referrals to be current and valid at the time of service. If the referral is expired or does not meet the specific requirements set by the insurance plan, the claim will be denied.
- Incorrect Coding or Documentation: Inaccurate coding or incomplete documentation can also lead to denial code 287. If the referring provider fails to include the necessary information or uses incorrect codes on the referral, the claim may be denied due to insufficient or incorrect documentation.
- Lack of Medical Necessity: Denial code 287 can also be triggered if the insurance company determines that the referral was not medically necessary. Insurance plans often require referrals to be based on medical necessity, meaning that the service or treatment must be deemed necessary for the patient’s health. If the insurance company determines that the referral was not medically necessary, the claim will be denied.
- Referral Not Authorized: Some insurance plans require prior authorization for certain services or treatments. If the referral was not properly authorized by the insurance company before the service was rendered, the claim may be denied under code 287.
3. Next Steps
You can fix denial code 287 as follows:
- Review Referral Limitations: First, review the patient’s insurance plan to understand the specific referral limitations for the service or treatment in question. Determine if the patient has already reached the maximum number of referrals allowed within the specified time period.
- Verify Referral Validity: Check the validity of the referral provided by the primary care physician. Ensure that the referral is current, meets the requirements set by the insurance plan, and is still valid at the time of service.
- Ensure Accurate Coding and Documentation: Double-check the coding and documentation related to the referral. Make sure that all necessary information is included and that the codes used accurately reflect the service or treatment being referred.
- Appeal the Denial: If you believe that the denial was in error, prepare an appeal with supporting documentation. This may include additional medical records, updated referrals, or any other relevant information that can demonstrate the medical necessity of the referral.
- Communicate with the Insurance Company: Contact the insurance company’s provider support to discuss the denial and provide any additional information or clarification they may require. Engage in a dialogue to resolve any misunderstandings or discrepancies regarding the referral.
- Coordinate with the Primary Care Physician: Work closely with the referring provider to ensure that future referrals are accurate, valid, and meet the requirements set by the insurance plan. Establish clear communication channels to avoid denials due to outdated or invalid referrals.
4. How To Avoid It
You can prevent denial code 287 in the future as follows:
- Understand Referral Limitations: Familiarize yourself with the referral limitations outlined in each patient’s insurance plan. Keep track of the number of referrals utilized and ensure that the patient does not exceed the allowed limit.
- Stay Updated on Referral Requirements: Stay informed about the specific requirements for referrals set by different insurance plans. Regularly review and update your knowledge to ensure that referrals meet the necessary criteria.
- Ensure Accurate Coding and Documentation: Pay close attention to coding and documentation related to referrals. Use the correct codes and include all necessary information to support the medical necessity of the referral.
- Verify Referral Validity: Before providing services based on a referral, verify the validity of the referral with the insurance company. Ensure that the referral is still valid and authorized for the specific service or treatment.
- Communicate with Patients: Educate patients about the importance of adhering to referral limitations and the potential consequences of exceeding them. Encourage open communication and prompt reporting of any changes or updates to their insurance coverage.
5. Example Cases
Below are two examples of denial code 287:
- Example 1: A patient has already reached the maximum number of referrals allowed for physical therapy sessions within a calendar year. When the provider submits a claim for an additional session, it is denied under code 287.
- Example 2: A primary care physician provides a referral for a specialist visit, but the referral does not meet the specific requirements set by the insurance plan. As a result, the claim for the specialist visit is denied under code 287.
