Denial Code 35 (CARC) means that a claim has been denied because the patient has reached their lifetime benefit maximum. Below you can find the description, common reasons for denial code 35, next steps, how to avoid it, and examples.
2. Description
Denial Code 35 is a Claim Adjustment Reason Code (CARC) and is described as ‘Lifetime benefit maximum has been reached’. This indicates that the insurance company will not make the payment for the billed service because the patient has exhausted their lifetime benefit maximum. Once the lifetime benefit maximum is reached, the insurance company will no longer provide coverage for any additional services.
2. Common Reasons
The most common reasons for denial code 35 are:
- Exhausted Lifetime Benefit: Denial code 35 occurs when the patient has utilized all the benefits available under their insurance plan. This can happen when the patient has received extensive medical treatment or has a chronic condition that requires ongoing care. Once the lifetime benefit maximum is reached, the insurance company will deny any further claims.
- Incorrect Billing: In some cases, denial code 35 may be triggered due to billing errors. This can include incorrect coding or billing for services that are not covered under the patient’s insurance plan. It is important to ensure that all services billed are eligible for coverage and accurately coded to avoid denials.
- Out-of-Network Providers: If the patient seeks treatment from an out-of-network provider, the insurance company may deny the claim under denial code 35. Out-of-network providers may not be covered under the patient’s insurance plan, and any services received from them will not contribute towards the lifetime benefit maximum.
- Non-Covered Services: Denial code 35 can also be triggered if the services rendered are not covered under the patient’s insurance plan. It is essential to verify coverage for specific services before providing them to the patient to avoid denials.
3. Next Steps
You can address denial code 35 as follows:
- Review Benefits Summary: First, review the patient’s benefits summary to confirm that the denial is due to reaching the lifetime benefit maximum. Ensure that all services billed are accurately reflected in the benefits summary and that the maximum limit has indeed been reached.
- Communicate with the Patient: Contact the patient to inform them about the denial and explain the reason behind it. Discuss alternative options for covering the cost of the services, such as self-payment or exploring other insurance coverage if available.
- Appeal the Denial: If you believe that the denial was in error or if there are extenuating circumstances, you can file an appeal with the insurance company. Provide any necessary documentation, such as medical records or proof of medical necessity, to support your appeal.
- Explore Financial Assistance: In cases where the patient is unable to afford the cost of the services, explore financial assistance options. This can include payment plans, charity care programs, or assistance from non-profit organizations.
- Coordinate with Other Providers: If the patient requires ongoing care, coordinate with other providers to ensure continuity of treatment. Explore options for transferring the patient’s care to an in-network provider or finding alternative resources to meet their healthcare needs.
4. How To Avoid It
You can prevent denial code 35 in the future by taking the following steps:
- Verify Coverage: Before providing any services, verify the patient’s insurance coverage and review the benefits summary. Ensure that the services to be rendered are covered under the patient’s plan and that there are no limitations or exclusions that could lead to denial.
- Monitor Lifetime Benefit Maximum: Keep track of the patient’s lifetime benefit maximum and communicate with them when they are approaching the limit. This allows for proactive planning and discussion of alternative options if the maximum is reached.
- Utilize In-Network Providers: Encourage patients to seek treatment from in-network providers whenever possible. In-network providers are more likely to be covered under the patient’s insurance plan, reducing the risk of denials due to out-of-network services.
- Accurate Coding and Billing: Ensure that all services are accurately coded and billed according to the patient’s insurance plan. This includes verifying coverage for specific services and using the appropriate codes to avoid denials.
5. Example Cases
Below are two examples of denial code 35:
- Example 1: A patient with a chronic condition has been receiving ongoing treatment for several years. After reaching their lifetime benefit maximum, any further claims for treatment related to the condition are denied under code 35.
- Example 2: A patient seeks treatment from an out-of-network specialist without verifying their insurance coverage. The claim is denied under code 35 as the services provided are not covered under the patient’s plan.
