How To Fix Denial Code 69 | Common Reasons, Next Steps & How To Avoid It

Denial Code 69 (CARC) means that a claim has been denied due to the day outlier amount. Below you can find the description, common reasons for denial code 69, next steps, how to avoid it, and examples.

2. Description

Denial Code 69 is a Claim Adjustment Reason Code (CARC) and is described as ‘Day Outlier Amount’. This denial code indicates that the claim has been denied because the billed amount for a specific day of service exceeds the expected or usual amount for that particular service. In simpler terms, the insurance company considers the billed amount for that day to be an outlier compared to what is typically charged for similar services.

2. Common Reasons

The most common reasons for denial code 69 are:

  1. Excessive Charges: Denial code 69 often occurs when the billed amount for a specific day of service is significantly higher than the average or expected cost for that service. This could be due to billing errors, inflated charges, or unusual circumstances that justify the higher cost.
  2. Lack of Documentation: Insufficient or inadequate documentation to support the billed charges for the specific day of service can result in denial code 69. Without proper documentation, the insurance company may consider the charges to be excessive or unjustified.
  3. Unusual Circumstances: Denial code 69 may also be triggered by unique or exceptional circumstances that justify higher charges for a specific day of service. However, if these circumstances are not properly documented or explained, the insurance company may deny the claim based on the outlier amount.
  4. Non-Standard Procedures: If the billed charges for a specific day of service involve non-standard or experimental procedures that are not typically covered by the insurance policy, denial code 69 may be applied. Insurance companies often have specific guidelines and limitations on what procedures they will cover, and any deviation from these guidelines can result in denial.
  5. Incorrect Coding: Inaccurate coding of the services provided on a specific day can lead to denial code 69. If the billed codes do not accurately reflect the services rendered or if there are coding errors, the insurance company may deny the claim based on the outlier amount.

3. Next Steps

You can address denial code 69 as follows:

  1. Review Documentation: Thoroughly review the documentation related to the specific day of service for which the claim was denied. Ensure that all relevant information, including the nature of the services provided and any unique circumstances, is properly documented and supported.
  2. Verify Billed Charges: Double-check the billed charges for the specific day of service to ensure accuracy. Compare the charges to the usual and customary fees for similar services to determine if they are within a reasonable range. If the charges are indeed excessive, consider whether there are valid justifications for the higher cost.
  3. Provide Additional Information: If the billed charges are justified due to unique circumstances or non-standard procedures, provide additional documentation or an explanation to support the outlier amount. This could include medical records, test results, or expert opinions that demonstrate the necessity and reasonableness of the charges.
  4. Appeal the Denial: If you believe that the denial was unjustified, submit an appeal to the insurance company. Include all relevant documentation and a detailed explanation of why the denial should be overturned. Follow the insurance company’s appeal process and provide any additional information or clarification they may request.
  5. Seek Professional Assistance: If you are facing challenges in resolving denial code 69, consider seeking assistance from a healthcare billing specialist or consultant. They can help navigate the appeals process, provide guidance on documentation requirements, and advocate on your behalf to ensure a fair resolution.

4. How To Avoid It

To avoid denial code 69 in the future, consider the following steps:

  1. Ensure Accurate Coding: Properly code the services provided on each day to accurately reflect the nature and complexity of the procedures. Regularly train and educate coding staff to stay updated on coding guidelines and best practices.
  2. Document Unusual Circumstances: If unique or exceptional circumstances justify higher charges for a specific day of service, ensure that these circumstances are thoroughly documented. Include any relevant medical records, test results, or expert opinions to support the necessity and reasonableness of the charges.
  3. Review Fee Schedules: Regularly review fee schedules and reimbursement rates to ensure that the billed charges for each day of service are within a reasonable range. Be aware of any limitations or exclusions in the insurance policies that may impact coverage for non-standard procedures.
  4. Implement Quality Assurance Measures: Establish quality assurance measures to review claims before submission. This can help identify any potential outliers or discrepancies in billed charges and documentation, allowing for corrections or additional information to be provided before the claim is submitted.

5. Example Cases

Below are two examples of denial code 69:

  • Example 1: A healthcare provider submits a claim for a routine procedure that is typically reimbursed at $500. However, the provider bills $2,000 for the same procedure on a specific day. The claim is denied under code 69 due to the significant difference in the billed amount compared to the usual and customary fee.
  • Example 2: A provider performs a non-standard procedure that is not covered by the patient’s insurance policy. The billed charges for that specific day exceed the usual and customary fee for similar procedures. As a result, the claim is denied under code 69.

Source: Claim Adjustment Reason Codes

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