How To Fix Denial Code 39 | Common Reasons, Next Steps & How To Avoid It

Denial Code 39 means that services have been denied because they were requested without proper authorization or pre-certification. In this article, we will provide a description of Denial Code 39, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of cases involving Denial Code 39.

2. Description

Denial Code 39 is a Claim Adjustment Reason Code (CARC) that indicates services have been denied because they were requested without the necessary authorization or pre-certification. Insurance companies require providers to obtain prior approval for certain services to ensure medical necessity and appropriate utilization. When services are rendered without obtaining the required authorization, the claim is denied under Denial Code 39.

2. Common Reasons

The most common reasons for Denial Code 39 include:

1. Lack of Authorization Request: Providers may fail to submit an authorization request to the insurance company before providing the services. This can occur due to administrative oversight, lack of awareness of the authorization requirement, or miscommunication between the provider and the insurance company.
2. Expired Authorization: Sometimes, providers may initiate services based on an authorization that has expired. Insurance companies typically set time limits for the validity of authorizations, and if services are rendered after the expiration date, the claim will be denied under Denial Code 39.
3. Inadequate Documentation: Insufficient or incomplete documentation supporting the medical necessity of the requested services can lead to denial under Denial Code 39. Insurance companies require detailed information to justify the need for specific treatments or procedures, and if this documentation is lacking, the claim will be denied.
4. Incorrect or Incomplete Information: Errors in the authorization request, such as missing or inaccurate patient information, service codes, or dates, can result in denial under Denial Code 39. It is crucial to ensure that all required information is provided accurately and completely to avoid denials.
5. Non-Covered Services: Some services may not be covered by the patient’s insurance plan, and authorization may be required for coverage. If services are rendered without obtaining the necessary authorization, the claim will be denied under Denial Code 39.

3. Next Steps

To resolve Denial Code 39, follow these next steps:

1. Review Authorization Requirements: Familiarize yourself with the specific authorization requirements of each insurance company you work with. Understand which services require prior approval and the process for submitting authorization requests.
2. Identify the Cause of Denial: Determine the reason for the denial by carefully reviewing the denial explanation provided by the insurance company. Identify any errors or deficiencies in the authorization request or supporting documentation.
3. Appeal the Denial: If you believe the denial was incorrect or unjustified, prepare an appeal. Include any missing or corrected information, additional documentation supporting medical necessity, and a clear explanation of why the denial should be overturned.
4. Communicate with the Insurance Company: Reach out to the insurance company’s provider support to discuss the denial and seek clarification if needed. Understand their requirements and expectations for obtaining authorization and ensure you have a clear understanding of the steps to take moving forward.
5. Update Authorization Processes: Implement measures to prevent future denials under Denial Code 39. Establish a system to track and manage authorization requests, ensuring they are submitted in a timely manner and that all necessary information is included.

4. How To Avoid It

To avoid Denial Code 39 in the future, consider the following tips:

1. Verify Authorization Requirements: Before providing services, confirm whether authorization is required for specific treatments or procedures. Check the patient’s insurance plan and communicate with the insurance company to ensure you have the most up-to-date information.
2. Submit Authorization Requests Timely: Submit authorization requests well in advance of the scheduled service to allow sufficient time for review and approval. Be aware of any time limits set by the insurance company for authorization validity.
3. Provide Complete and Accurate Information: Double-check all patient information, service codes, and dates when submitting authorization requests. Ensure that all required documentation supporting medical necessity is included.
4. Educate Staff and Patients: Train your staff on the importance of obtaining proper authorization and provide them with the necessary tools and resources to navigate the authorization process effectively. Educate patients about their insurance coverage and the need for authorization to manage their expectations.

5. Example Cases

Here are two examples of cases involving Denial Code 39:

• Example 1: A provider performs a specialized diagnostic test without obtaining prior authorization from the insurance company. The claim is subsequently denied under Denial Code 39 due to the lack of authorization.
• Example 2: A provider submits an authorization request for a surgical procedure but fails to include the required supporting documentation. The claim is denied under Denial Code 39 because the insurance company did not receive sufficient evidence of medical necessity.

Source: Claim Adjustment Reason Codes