How To Fix Denial Code 297 | Common Reasons, Next Steps & How To Avoid It

Denial Code 297 means that a claim has been received by the medical plan, but benefits are not available under this specific plan. In order to resolve this issue, the services should be submitted to the patient’s vision plan for further consideration. Below you can find a detailed description of denial code 297, common reasons for its occurrence, next steps to take, how to avoid it in the future, and examples of denial code 297 cases.

2. Description

Denial Code 297 is a claim adjustment reason code (CARC) that indicates the claim has been received by the medical plan, but the benefits are not available under this particular plan. This means that the services billed are not covered by the medical plan and should be submitted to the patient’s vision plan for further consideration. It is important to understand the specific coverage limitations of the medical plan and ensure that the services being billed are eligible for reimbursement.

2. Common Reasons

The most common reasons for denial code 297 are:

1. Limited Coverage: Denial code 297 often occurs when the medical plan has limited coverage for certain services or procedures. This could be due to specific exclusions or limitations outlined in the plan’s policy. It is important to review the plan’s coverage details and verify if the services being billed are covered.
2. Out-of-Network Providers: If the provider is not in-network with the medical plan, denial code 297 may be triggered. Some plans only provide benefits for services rendered by in-network providers. It is crucial to confirm the provider’s network status before submitting claims.
3. Incorrect Coding: Inaccurate coding can lead to denial code 297. If the services are coded incorrectly or do not align with the covered services under the medical plan, the claim may be denied. It is essential to use the correct coding guidelines and ensure accurate representation of the services provided.
4. Missing Prior Authorization: Certain services may require prior authorization from the medical plan. If the necessary authorization is not obtained before providing the services, denial code 297 may be issued. It is important to verify the prior authorization requirements and obtain the necessary approvals.
5. Expired Coverage: Denial code 297 can occur if the patient’s coverage under the medical plan has expired or is no longer active. It is crucial to verify the patient’s coverage status before submitting claims to avoid denials.

3. Next Steps

To address denial code 297, the following steps can be taken:

1. Review Plan Coverage: Carefully review the medical plan’s coverage details to determine if the services being billed are eligible for reimbursement. Identify any limitations or exclusions that may apply.
2. Submit to Vision Plan: If the services are related to vision care and are not covered by the medical plan, submit the claim to the patient’s vision plan for further consideration. Ensure that the claim is submitted following the vision plan’s guidelines and requirements.
3. Appeal or Resubmit: If you believe that the denial was in error or if there is additional information that can support the claim, consider appealing the denial or resubmitting the claim with the necessary documentation. Follow the specific procedures outlined by the medical plan or vision plan.
4. Communicate with the Patient: Keep the patient informed about the denial and the next steps being taken to resolve the issue. Provide clear explanations and guidance on how they can assist in the process, such as providing any necessary documentation or contacting their vision plan.
5. Document and Track: Maintain detailed records of all communication, claim submissions, and any additional documentation provided. This will help in tracking the progress of the claim and ensuring that all necessary steps have been taken.

4. How To Avoid It

To avoid denial code 297 in the future, consider the following strategies:

1. Verify Coverage: Before providing any services, verify the patient’s coverage under the medical plan. Confirm the specific benefits and limitations that apply to the services being rendered.
2. Check Network Status: Ensure that the provider is in-network with the medical plan. If the provider is out-of-network, inform the patient about potential out-of-pocket expenses or consider referring them to an in-network provider.
3. Accurate Coding: Use accurate and up-to-date coding guidelines to ensure that the services are coded correctly. Regularly review coding updates and guidelines to stay informed about any changes that may impact reimbursement.
4. Prior Authorization: Determine if any services require prior authorization from the medical plan. Obtain the necessary approvals before providing the services to avoid denials.
5. Stay Updated: Keep track of any changes or updates to the patient’s coverage or the medical plan’s policies. Regularly communicate with the medical plan to stay informed about any modifications that may affect reimbursement.

5. Example Cases

Here are two examples of denial code 297:

• Example 1: A patient visits an out-of-network optometrist for an eye exam and submits a claim to their medical plan. The claim is denied under denial code 297 because the medical plan does not cover vision care services. The patient is advised to submit the claim to their vision plan for further consideration.
• Example 2: A provider submits a claim for a cosmetic procedure to a patient’s medical plan. The claim is denied under denial code 297 because the medical plan explicitly excludes coverage for cosmetic procedures. The provider advises the patient to explore alternative payment options or consider submitting the claim to a different insurance plan, if applicable.

Source: Claim Adjustment Reason Codes