How To Fix Denial Code 288 | Common Reasons, Next Steps & How To Avoid It

Denial Code 288 (CARC) means that a claim has been denied because the referral for the service is absent. Below you can find the description, common reasons for denial code 288, next steps, how to avoid it, and examples.

2. Description

Denial Code 288 is a Claim Adjustment Reason Code (CARC) and is described as ‘Referral Absent’. This indicates that the insurance company will not make the payment for the billed service because the required referral for the service is missing. In simpler terms, the claim is not payable until the necessary referral is obtained and submitted with the claim.

2. Common Reasons

The most common reasons for denial code 288 are:

1. Lack of Referral: Denial code 288 is often triggered when a healthcare provider fails to obtain the required referral from the primary care physician or the referring specialist. Insurance plans may have specific guidelines that require a referral for certain services, and without it, the claim will be denied.
2. Expired Referral: In some cases, the referral may have been obtained, but it has expired by the time the claim is submitted. Insurance companies typically have time limits on referrals, and if the claim is not filed within the specified timeframe, it will be denied under code 288.
3. Incomplete Referral Information: Another reason for denial code 288 is when the referral information provided is incomplete or inaccurate. This could include missing or incorrect patient identifiers, referring provider information, or details about the service being referred. Incomplete information can lead to claim denials.
4. Referral Not on File: Sometimes, the referral may have been obtained, but it was not properly documented or filed by the healthcare provider. If the insurance company does not have a record of the referral, the claim will be denied under code 288.
5. Referral Not Medically Necessary: Insurance plans may require referrals to ensure that services are medically necessary. If the insurance company determines that the referral was not justified or the service does not meet their criteria for medical necessity, the claim will be denied.

3. Next Steps

You can fix denial code 288 as follows:

1. Obtain the Required Referral: The first step is to ensure that the necessary referral is obtained from the primary care physician or the referring specialist. Check with the insurance company to understand their specific referral requirements and guidelines.
2. Verify Referral Expiration: If you have obtained the referral, make sure to check its expiration date. Ensure that the claim is submitted within the timeframe specified by the insurance company to avoid denial under code 288.
3. Review Referral Information: Double-check the referral information provided on the claim. Make sure that all the required details, such as patient identifiers, referring provider information, and service being referred, are accurate and complete.
4. Submit Referral Documentation: If the denial was due to the referral not being on file, gather the necessary documentation to prove that the referral was obtained. This may include a copy of the referral form or any other supporting documentation.
5. Appeal the Denial: If you believe that the denial was incorrect or unjustified, you have the option to appeal the denial. Follow the insurance company’s appeal process and provide any additional information or documentation that supports the medical necessity of the service.
6. Improve Referral Management: To avoid future denials under code 288, implement a robust referral management system. This may involve educating staff on referral requirements, implementing processes to track and document referrals, and regularly reviewing and updating referral guidelines.

4. How To Avoid It

You can prevent denial code 288 in the future as follows:

1. Understand Referral Requirements: Familiarize yourself with the referral requirements of different insurance plans. Each plan may have specific guidelines regarding when referrals are necessary and how they should be obtained.
2. Educate Staff and Providers: Train your staff and providers on the importance of obtaining and documenting referrals. Make sure they understand the specific referral requirements for each insurance plan and the potential consequences of not following them.
3. Implement Referral Tracking System: Establish a system to track and document referrals. This can help ensure that referrals are obtained, properly documented, and submitted with the claim within the specified timeframe.
4. Regularly Review Referral Guidelines: Stay updated on any changes to referral guidelines or requirements. Regularly review and update your referral processes to align with the latest guidelines to avoid denials under code 288.

5. Example Cases

Below are two examples of denial code 288:

• Example 1: A patient visits a specialist without obtaining a referral from their primary care physician, as required by their insurance plan. The claim for the specialist visit is denied under code 288 due to the absence of the required referral.
• Example 2: A healthcare provider submits a claim for a service with a referral that has expired. The claim is denied under code 288 because the referral was not submitted within the specified timeframe.

Source: Claim Adjustment Reason Codes