Denial Code 61 (CARC) means that a claim has been adjusted because the provider failed to obtain a second surgical opinion. Below you can find the description, common reasons for denial code 61, next steps, how to avoid it, and examples.
2. Description
Denial Code 61 is a Claim Adjustment Reason Code (CARC) and is described as ‘Adjusted for failure to obtain second surgical opinion’. This indicates that the insurance company has adjusted the claim because the provider did not follow the necessary protocol of obtaining a second surgical opinion. In simpler terms, the claim is not payable because the required second opinion was not obtained.
2. Common Reasons
The most common reasons for denial code 61 are:
- Lack of Second Surgical Opinion: Denial code 61 is triggered when the provider fails to obtain a second surgical opinion as required by the insurance company. This could be due to oversight, lack of awareness of the requirement, or failure to follow the established guidelines.
- Insufficient Documentation: In some cases, even if a second surgical opinion was obtained, the documentation provided may not meet the insurance company’s requirements. This can result in denial code 61 if the necessary information is not adequately documented or if the documentation does not support the need for the second opinion.
- Incorrect Coding: Denial code 61 can also occur if there are coding errors related to the requirement for a second surgical opinion. If the procedure or diagnosis codes do not align with the need for a second opinion, the claim may be denied.
- Missed Deadlines: Insurance companies often have specific timeframes within which a second surgical opinion must be obtained. If the provider fails to meet these deadlines, the claim may be denied under denial code 61.
3. Next Steps
You can address denial code 61 as follows:
- Review Insurance Guidelines: Familiarize yourself with the insurance company’s guidelines regarding the requirement for a second surgical opinion. Understand the specific criteria and documentation needed to meet this requirement.
- Educate Providers: Ensure that all providers are aware of the requirement for a second surgical opinion and understand the importance of obtaining one. Provide training and resources to support compliance with insurance guidelines.
- Implement Documentation Processes: Establish clear processes for documenting the second surgical opinion. Ensure that all necessary information is included and that it aligns with the insurance company’s requirements. This may involve creating templates or checklists to guide providers in gathering the required documentation.
- Monitor Deadlines: Keep track of the deadlines set by the insurance company for obtaining the second surgical opinion. Implement systems or reminders to ensure that these deadlines are met consistently.
- Appeal Denials: If a claim is denied under denial code 61, review the denial letter and determine if there are grounds for appeal. If the second surgical opinion was obtained but not adequately documented, provide additional supporting documentation to challenge the denial. If the denial was due to coding errors, correct the coding and resubmit the claim.
- Communicate with Patients: Keep patients informed about the requirement for a second surgical opinion and the potential impact on their claims. Educate them about the importance of following the insurance company’s guidelines to avoid denials.
4. How To Avoid It
You can prevent denial code 61 in the future by taking the following steps:
- Verify Insurance Requirements: Before scheduling any surgical procedures, verify the insurance company’s requirements regarding second surgical opinions. Ensure that you understand the specific criteria and documentation needed to meet this requirement.
- Educate Patients: Clearly communicate the need for a second surgical opinion to patients. Explain the insurance company’s guidelines and the potential impact on their claims if this requirement is not met. Encourage patients to seek a second opinion and provide them with resources or referrals to facilitate the process.
- Document Thoroughly: When obtaining a second surgical opinion, ensure that all necessary information is documented accurately and completely. Include the date of the opinion, the name of the provider who performed the evaluation, and any relevant findings or recommendations. This documentation will be crucial in supporting the claim and avoiding denials.
- Submit Claims Promptly: Once the second surgical opinion has been obtained and the procedure is scheduled, submit the claim promptly to avoid any potential issues with missed deadlines. Timely submission will help ensure that the claim is processed without delays or denials.
5. Example Cases
Below are two examples of denial code 61:
- Example 1: A provider schedules a surgical procedure without obtaining a second surgical opinion as required by the insurance company. The claim is subsequently denied under denial code 61.
- Example 2: A provider obtains a second surgical opinion but fails to adequately document the opinion or include the necessary information in the claim. The claim is denied under denial code 61 due to insufficient documentation.
