How To Fix Denial Code 8 | Common Reasons, Next Steps & How To Avoid It

Denial Code 8 means that the procedure code is inconsistent with the provider type/specialty (taxonomy). This denial code indicates that there is a mismatch between the procedure being billed and the type of provider or specialty associated with the claim. In this article, we will explore the description of denial code 8, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples to illustrate its application.

2. Description

Denial Code 8 is a Claim Adjustment Reason Code (CARC) that signifies an inconsistency between the procedure code and the provider type/specialty (taxonomy). This means that the billed procedure does not align with the type of provider or specialty associated with the claim. The 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) can be referenced to gain further insight into the specific policy details related to this denial code.

2. Common Reasons

The most common reasons for denial code 8 are:

1. Incorrect Provider Type: One of the main reasons for denial code 8 is when the procedure code is billed under a provider type or specialty that does not match the services being rendered. This could occur due to a coding error or a misunderstanding of the correct provider type associated with the procedure.
2. Outdated Provider Information: Denial code 8 may also be triggered if the provider’s information, such as their taxonomy code, is outdated or incorrect. Insurance companies rely on accurate provider information to determine if the billed procedure aligns with the provider’s designated type or specialty.
3. Unrecognized Provider Specialty: Some denial code 8 occurrences may arise when the insurance company does not recognize the provider’s specialty or the specialty associated with the procedure code. This could be due to discrepancies in how the provider is registered or classified within the insurance company’s system.
4. Invalid Procedure Code: Another reason for denial code 8 is when the procedure code itself is invalid or not recognized by the insurance company. This could be due to using outdated or non-standard procedure codes that are not accepted by the payer.

3. Next Steps

To resolve denial code 8, the following steps can be taken:

1. Review Claim Details: Carefully review the claim details, including the procedure code, provider information, and any associated taxonomy codes. Identify any discrepancies or errors that may have led to the denial.
2. Verify Provider Type/Specialty: Confirm that the provider’s type or specialty aligns with the billed procedure. Ensure that the correct taxonomy code is used and that it accurately reflects the provider’s qualifications and expertise.
3. Update Provider Information: If the denial was due to outdated or incorrect provider information, update the necessary details with the insurance company. This may involve updating the provider’s taxonomy code or other relevant information to ensure accurate billing.
4. Appeal or Correct Claim: If the denial was a result of an error or misunderstanding, consider appealing the denial or correcting the claim. Provide any additional documentation or clarification that supports the appropriate alignment between the procedure code and the provider’s type or specialty.
5. Communicate with Payer: If there is confusion or disagreement regarding the denial, reach out to the insurance company’s provider support to discuss the specifics of the claim and seek clarification on their requirements or expectations.

4. How To Avoid It

To avoid denial code 8 in the future, consider the following measures:

1. Ensure Accurate Coding: Double-check that the procedure codes being used are accurate, up-to-date, and recognized by the insurance company. Regularly review and update coding practices to align with industry standards and payer requirements.
2. Verify Provider Information: Maintain accurate and updated provider information, including taxonomy codes and specialty designations. Regularly review and update provider profiles to ensure that the information aligns with the services being rendered.
3. Stay Informed: Stay updated on changes in coding guidelines, payer policies, and industry standards. This will help ensure that the procedure codes being used are appropriate and align with the provider’s type or specialty.
4. Educate Staff: Provide training and education to billing and coding staff to ensure they understand the importance of accurate coding and the potential impact of using incorrect procedure codes or provider information.

5. Example Cases

Here are two examples illustrating denial code 8:

• Example 1: A dentist submits a claim for a complex oral surgery procedure using a procedure code typically associated with orthopedic surgeons. The claim is denied under denial code 8 due to the inconsistency between the procedure code and the provider’s specialty.
• Example 2: A physical therapist bills for a specialized therapy session using a procedure code that is not recognized by the insurance company. The claim is denied under denial code 8 as the procedure code is invalid or not accepted by the payer.

Source: Claim Adjustment Reason Codes