How To Fix Denial Code 292 | Common Reasons, Next Steps & How To Avoid It

Denial Code 292 means that a claim has been received by the medical plan, but benefits are not available under this plan. The claim has been forwarded to the patient’s pharmacy plan for further consideration. In this article, we will provide a description of denial code 292, common reasons for its occurrence, next steps to take when faced with this denial code, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 292 is a claim adjustment reason code (CARC) that indicates that the medical plan has received the claim, but the benefits for the services rendered are not available under this particular plan. As a result, the claim has been forwarded to the patient’s pharmacy plan for further consideration. This denial code is typically used when the services being claimed fall under the scope of the pharmacy plan rather than the medical plan.

2. Common Reasons

The most common reasons for denial code 292 are:

1. Service Coverage Limitations: Denial code 292 may occur when the medical plan does not provide coverage for the specific services or treatments being claimed. This could be due to limitations outlined in the plan’s policy, such as exclusions for certain procedures or therapies.
2. Pharmacy Plan Requirement: Denial code 292 may also be triggered when the services being claimed are typically covered under the patient’s pharmacy plan rather than the medical plan. This could include prescription medications, durable medical equipment, or other pharmacy-related services.
3. Incorrect Billing: In some cases, denial code 292 may occur due to billing errors or inaccuracies. This could include coding errors, incorrect submission of claims to the wrong plan, or failure to properly indicate that the services should be processed under the pharmacy plan.
4. Lack of Coordination: Denial code 292 may result from a lack of coordination between the medical plan and the pharmacy plan. This could occur when there is confusion or miscommunication regarding which plan should be responsible for covering specific services.

3. Next Steps

If you receive denial code 292, here are the next steps to take:

1. Review the Claim: Carefully review the claim to ensure that it was submitted correctly and that all necessary information is included. Check for any billing errors or inaccuracies that may have contributed to the denial.
2. Contact the Pharmacy Plan: Reach out to the patient’s pharmacy plan to inquire about the status of the forwarded claim. Provide any additional information or documentation that may be required to support the claim.
3. Clarify Coverage: If there is confusion about which plan should be responsible for covering the services, contact both the medical plan and the pharmacy plan to clarify coverage and ensure that the claim is being processed correctly.
4. Appeal if Necessary: If you believe that the denial was made in error or that the services should be covered under the medical plan, consider filing an appeal. Provide any supporting documentation or evidence to strengthen your case.
5. Update Billing Practices: To avoid future denials under code 292, ensure that your billing practices are accurate and up to date. Double-check that claims are being submitted to the correct plan and that all necessary information is included.

4. How To Avoid It

To prevent denial code 292 in the future, consider the following steps:

1. Verify Coverage: Before providing services, verify the patient’s coverage and determine which plan should be responsible for the specific services being rendered. This will help ensure that claims are submitted to the correct plan.
2. Coordinate with Pharmacy Plan: If the services being provided are typically covered under the patient’s pharmacy plan, coordinate with the pharmacy plan to ensure that the claim is processed correctly and that coverage is confirmed.
3. Train Staff: Educate your billing and administrative staff about the differences between medical and pharmacy plans and how to properly submit claims to each. Provide ongoing training to keep them updated on any changes in coverage or billing requirements.
4. Double-Check Claims: Before submitting claims, double-check that all necessary information is included and that the claim is being submitted to the appropriate plan. This will help minimize the risk of denials due to billing errors or inaccuracies.

5. Example Cases

Here are two examples of denial code 292:

• Example 1: A patient submits a claim for a prescription medication to their medical plan. However, the medical plan does not cover prescription medications and forwards the claim to the patient’s pharmacy plan for further consideration.
• Example 2: A healthcare provider mistakenly submits a claim for durable medical equipment to the patient’s medical plan instead of the pharmacy plan. The medical plan denies the claim under code 292 and forwards it to the pharmacy plan for review.

Source: Claim Adjustment Reason Codes