How To Fix Denial Code 75 | Common Reasons, Next Steps & How To Avoid It

Denial Code 75 (CARC) means that a claim has been adjusted due to Direct Medical Education (DME) expenses. Below you can find the description, common reasons for denial code 75, next steps, how to avoid it, and examples.

2. Description

Denial Code 75 is a Claim Adjustment Reason Code (CARC) and is described as ‘Direct Medical Education Adjustment’. This code indicates that the insurance company has made an adjustment to the claim due to Direct Medical Education expenses. Direct Medical Education refers to the costs associated with the training and education of medical professionals, such as residents and interns, in a clinical setting.

2. Common Reasons

The most common reasons for denial code 75 are:

1. Ineligible DME Expenses: Denial code 75 may be triggered if the claimed expenses for Direct Medical Education are deemed ineligible by the insurance company. This could be due to the nature of the expenses or if they do not meet the specific criteria outlined in the insurance policy.
2. Lack of Documentation: Insufficient or incomplete documentation supporting the Direct Medical Education expenses can lead to denial code 75. It is essential to provide detailed and accurate documentation that clearly demonstrates the necessity and appropriateness of the claimed expenses.
3. Exceeding Coverage Limits: Some insurance policies have limits on the coverage provided for Direct Medical Education expenses. If the claimed expenses exceed these limits, denial code 75 may be applied.
4. Missing or Incorrect Coding: Errors in coding, such as using incorrect procedure codes or failing to include the appropriate modifiers, can result in denial code 75. It is crucial to ensure accurate coding to avoid claim denials.
5. Non-Compliance with Policy Requirements: Insurance policies may have specific requirements or guidelines regarding the submission of Direct Medical Education expenses. Failure to comply with these requirements can lead to denial code 75.

3. Next Steps

You can address denial code 75 as follows:

1. Review Policy Coverage: Familiarize yourself with the insurance policy’s coverage for Direct Medical Education expenses. Ensure that the claimed expenses align with the policy’s guidelines and limitations.
2. Documentation Verification: Double-check the documentation supporting the claimed Direct Medical Education expenses. Ensure that all necessary documentation is complete, accurate, and clearly demonstrates the necessity and appropriateness of the expenses.
3. Appeal or Resubmit: If the denial was due to missing or incorrect coding, consider appealing the denial or resubmitting the claim with the correct coding. Provide any additional documentation or information that supports the eligibility and appropriateness of the claimed expenses.
4. Communicate with the Insurance Company: If there is confusion or disagreement regarding the denial, reach out to the insurance company’s provider support. Discuss the specifics of the claim and seek clarification on the reasons for the denial. This communication can help resolve any misunderstandings or provide guidance on how to properly submit Direct Medical Education expenses.
5. Update Coding and Billing Practices: Ensure that your coding and billing practices are up to date and accurate. Stay informed about any changes or updates in coding guidelines and requirements related to Direct Medical Education expenses.

4. How To Avoid It

You can prevent denial code 75 in the future by following these steps:

1. Understand Policy Requirements: Familiarize yourself with the insurance policy’s guidelines and requirements for Direct Medical Education expenses. Ensure that you are aware of any coverage limits or specific documentation needed.
2. Accurate Coding: Ensure that the coding for Direct Medical Education expenses is accurate and follows the guidelines provided by the insurance company. Use the appropriate procedure codes and modifiers to avoid claim denials.
3. Thorough Documentation: Maintain detailed and comprehensive documentation for all Direct Medical Education expenses. Include supporting documents that clearly demonstrate the necessity and appropriateness of the claimed expenses.
4. Regular Policy Review: Stay updated on any changes or updates to the insurance policy’s coverage for Direct Medical Education expenses. Regularly review the policy to ensure compliance with the latest requirements.

5. Example Cases

Below are two examples of denial code 75:

• Example 1: A healthcare provider submits a claim for Direct Medical Education expenses related to a resident’s training program. However, the insurance company denies the claim under code 75, stating that the claimed expenses exceed the coverage limits specified in the policy.
• Example 2: In another scenario, a provider fails to include the necessary documentation supporting the claimed Direct Medical Education expenses. As a result, the claim is denied under code 75 due to insufficient documentation.

Source: Claim Adjustment Reason Codes