How To Fix Denial Code 304 | Common Reasons, Next Steps & How To Avoid It

Denial Code 304 means that a claim has been received by the medical plan, but the benefits are not available under this specific plan. In order to resolve this issue, the services should be submitted to the patient’s hearing plan for further consideration. Below you can find a detailed description of denial code 304, common reasons for its occurrence, next steps to take, how to avoid it in the future, and examples of denial code 304 cases.

2. Description

Denial Code 304 is a specific claim adjustment reason code (CARC) that indicates that the claim has been received by the medical plan, but the benefits are not available under the plan in question. This means that the services billed are not covered by the patient’s current medical plan, and therefore, the claim is denied. To resolve this issue, the services should be submitted to the patient’s hearing plan for further consideration.

2. Common Reasons

The most common reasons for denial code 304 are:

1. Inadequate Coverage: Denial code 304 often occurs when the patient’s medical plan does not provide coverage for the specific services that were billed. This could be due to limitations or exclusions in the plan’s coverage policy.
2. Incorrect Plan Selection: Sometimes, the wrong medical plan may have been selected or entered during the claim submission process. This can result in denial code 304 if the services are not covered under the chosen plan.
3. Out-of-Network Providers: If the services were provided by an out-of-network provider, the patient’s medical plan may not provide coverage for these services. This can lead to denial code 304.
4. Missing Authorization: Certain services may require prior authorization from the medical plan in order to be covered. If the necessary authorization was not obtained before the services were rendered, denial code 304 may be issued.
5. Expired Coverage: If the patient’s medical plan coverage has expired or been terminated, denial code 304 may be triggered as the benefits are no longer available under the plan.

3. Next Steps

To address denial code 304, the following steps should be taken:

1. Review Plan Coverage: Verify the patient’s medical plan coverage to determine if the services that were billed are indeed not covered under the plan. This can be done by contacting the insurance company or reviewing the plan documents.
2. Submit to Hearing Plan: If it is determined that the services should be covered under the patient’s hearing plan, submit the claim to the appropriate plan for further consideration. Ensure that all necessary documentation and information are included with the claim submission.
3. Follow Up with Hearing Plan: After submitting the claim to the hearing plan, follow up with them to ensure that the claim is being processed and reviewed. Provide any additional information or documentation that may be requested by the hearing plan.
4. Appeal if Necessary: If the claim is still denied by the hearing plan, consider filing an appeal. This may involve providing additional supporting documentation or working with the patient to gather any relevant information that could help overturn the denial.
5. Explore Other Options: If the claim continues to be denied, explore other options such as patient assistance programs or alternative funding sources to help cover the cost of the services.

4. How To Avoid It

To avoid denial code 304 in the future, consider the following steps:

1. Verify Coverage: Before providing any services, verify the patient’s medical plan coverage to ensure that the services will be covered. This can be done by contacting the insurance company or using online tools provided by the plan.
2. Check Network Status: If the patient is seeing a specialist or provider outside of their network, confirm whether the services will be covered by the medical plan. If not, consider alternative options or discuss with the patient the potential out-of-pocket costs.
3. Obtain Authorization: For services that require prior authorization, make sure to obtain the necessary approval from the medical plan before providing the services. This will help ensure that the services will be covered and minimize the risk of denial.
4. Stay Informed: Keep up-to-date with any changes or updates to the patient’s medical plan coverage policies. This can help avoid surprises and denials due to changes in coverage.

5. Example Cases

Below are two examples of denial code 304:

• Example 1: A patient submits a claim for a hearing aid fitting to their medical plan, but the claim is denied under denial code 304. Upon review, it is discovered that the patient’s medical plan does not provide coverage for hearing aids. The claim should be submitted to the patient’s hearing plan for further consideration.
• Example 2: A provider mistakenly submits a claim for a dental procedure to the patient’s medical plan instead of their dental plan. The claim is denied under denial code 304 as the services are not covered under the medical plan. The claim should be resubmitted to the patient’s dental plan for review.

Source: Claim Adjustment Reason Codes