How To Fix Denial Code 31 | Common Reasons, Next Steps & How To Avoid It

Denial Code 31 means that the patient cannot be identified as our insured. This denial code indicates that the insurance company is unable to verify the patient’s coverage and therefore cannot process the claim. In this article, we will provide a detailed description of denial code 31, common reasons for its occurrence, next steps to resolve the issue, tips on how to avoid it in the future, and examples of denial code 31 cases.

2. Description

Denial Code 31 is a Claim Adjustment Reason Code (CARC) that signifies the inability to identify the patient as our insured. This means that the insurance company cannot confirm the patient’s coverage and, as a result, cannot proceed with processing the claim. It is crucial to resolve this issue to ensure that the patient receives the necessary healthcare services without any financial burden.

2. Common Reasons

There are several common reasons why denial code 31 may occur:

1. Inaccurate Patient Information: One of the primary reasons for denial code 31 is when the patient’s information provided on the claim is incorrect or incomplete. This could include errors in the patient’s name, date of birth, insurance policy number, or other relevant details. Without accurate information, the insurance company cannot verify the patient’s coverage.
2. Lapsed or Terminated Insurance Coverage: If the patient’s insurance policy has expired or been terminated, denial code 31 may be triggered. It is essential to ensure that the patient’s coverage is active and up to date before submitting the claim.
3. Incorrect Insurance Provider: Another reason for denial code 31 is when the claim is submitted to the wrong insurance provider. This can happen if there is confusion or a mistake in identifying the correct insurance company responsible for the patient’s coverage. Verifying the correct insurance provider is crucial to avoid this denial code.
4. Missing or Invalid Insurance Policy Number: When the insurance policy number provided on the claim is missing or invalid, denial code 31 may be issued. It is essential to double-check and confirm that the policy number is accurate and corresponds to the patient’s current insurance coverage.
5. Out-of-Network Services: If the healthcare provider is not in the patient’s insurance network, denial code 31 may be applied. It is crucial to verify the provider’s network status and inform the patient of any potential out-of-network charges before rendering services.

3. Next Steps

To resolve denial code 31, the following steps should be taken:

1. Verify Patient Information: Review the patient’s information provided on the claim and ensure its accuracy. Check for any missing or incorrect details, such as the patient’s name, date of birth, or insurance policy number. Correct any errors before resubmitting the claim.
2. Contact the Insurance Company: Reach out to the patient’s insurance company to verify their coverage and resolve any issues. Provide the necessary information and documentation to confirm the patient’s eligibility for benefits.
3. Update Insurance Information: If the patient’s insurance coverage has lapsed or been terminated, work with the patient to update their insurance information. This may involve obtaining new insurance details or assisting the patient in renewing their coverage.
4. Submit a Corrected Claim: Once the patient’s information has been verified and updated, submit a corrected claim with the accurate and complete details. Ensure that the claim is sent to the correct insurance provider and includes the valid insurance policy number.
5. Follow Up with the Insurance Company: After resubmitting the corrected claim, follow up with the insurance company to confirm that the issue has been resolved and the claim is being processed. Address any additional requirements or inquiries promptly to expedite the claim’s approval.

4. How To Avoid It

To avoid denial code 31 in the future, consider the following tips:

1. Double-Check Patient Information: Before submitting a claim, verify that all patient information is accurate and up to date. This includes the patient’s name, date of birth, insurance policy number, and any other relevant details.
2. Confirm Insurance Coverage: Ensure that the patient’s insurance coverage is active and valid. Regularly check for any changes or updates to the patient’s insurance policy to avoid submitting claims with outdated information.
3. Verify Insurance Provider: Confirm the correct insurance provider responsible for the patient’s coverage. Keep a record of the insurance company’s contact information for easy reference when needed.
4. Stay In-Network: If possible, provide services within the patient’s insurance network to avoid potential denials due to out-of-network charges. Inform the patient of any potential out-of-network costs before rendering services.
5. Train Staff on Insurance Procedures: Educate your billing and administrative staff on the importance of accurate insurance information and the proper procedures for verifying coverage. Regular training can help minimize errors and prevent denials.

5. Example Cases

Here are two examples of denial code 31:

• Example 1: A healthcare provider submits a claim for a patient but mistakenly enters an incorrect insurance policy number. As a result, the claim is denied under denial code 31 since the insurance company cannot identify the patient as their insured.
• Example 2: A patient’s insurance coverage has expired, but the healthcare provider is unaware of this change. The provider submits a claim, but it is denied under denial code 31 due to the patient’s lapsed coverage.

Source: Claim Adjustment Reason Codes