Denial Code 89 (CARC) means that professional fees have been removed from the charges on a claim. Below you can find the description, common reasons for denial code 89, next steps, how to avoid it, and examples.
2. Description
Denial Code 89 is a Claim Adjustment Reason Code (CARC) and is described as ‘Professional fees removed from charges’. This code indicates that the insurance company has removed the professional fees from the charges on the claim. In other words, the payment for the professional services rendered has been denied or reduced.
2. Common Reasons
The most common reasons for denial code 89 are:
- Non-Covered Services: Denial code 89 may be triggered when the insurance policy does not cover the specific professional services that were billed. This could be due to limitations or exclusions outlined in the policy, or because the services are considered experimental or investigational.
- Incorrect Coding: If the professional services were coded incorrectly on the claim, it can result in denial code 89. This could include using an incorrect CPT code, failing to provide sufficient documentation to support the services rendered, or using a code that is not recognized by the insurance company.
- Lack of Medical Necessity: Insurance companies often require that services be medically necessary in order to be covered. If the insurance company determines that the professional services were not medically necessary, they may deny or reduce payment, resulting in denial code 89.
- Out-of-Network Providers: If the professional services were provided by an out-of-network provider and the insurance policy does not provide coverage for out-of-network services, denial code 89 may be applied. This can result in the insurance company denying or reducing payment for the services rendered.
- Pre-Authorization Requirements: Some insurance policies require pre-authorization for certain professional services. If the services were not pre-authorized as required by the policy, the insurance company may deny or reduce payment, leading to denial code 89.
3. Next Steps
You can address denial code 89 by taking the following steps:
- Review the Explanation of Benefits (EOB): Carefully review the EOB provided by the insurance company to understand the specific reason for denial code 89. This will help you identify the underlying issue and determine the appropriate next steps.
- Verify Coverage and Policy Terms: Confirm the coverage and policy terms for the professional services rendered. Ensure that the services are covered under the patient’s insurance policy and that any requirements, such as pre-authorization, have been met.
- Appeal the Denial: If you believe that the denial was incorrect or unjustified, you can file an appeal with the insurance company. Provide any necessary documentation, such as medical records or additional information supporting the medical necessity of the services rendered.
- Communicate with the Patient: Keep the patient informed about the denial and the steps being taken to address it. Discuss any potential financial responsibility the patient may have as a result of the denial and explore alternative payment options if necessary.
- Consider Negotiation: In some cases, it may be possible to negotiate with the insurance company to reach a resolution. This could involve discussing the denial with a claims representative or seeking assistance from a healthcare advocate or legal professional.
4. How To Avoid It
To avoid denial code 89 in the future, consider the following strategies:
- Verify Coverage and Eligibility: Before providing professional services, verify the patient’s insurance coverage and eligibility. Confirm that the services are covered under the patient’s policy and that any requirements, such as pre-authorization, are met.
- Accurate Coding and Documentation: Ensure that professional services are coded accurately and supported by appropriate documentation. Use the correct CPT codes and provide detailed documentation that clearly demonstrates the medical necessity of the services rendered.
- Stay In-Network: Whenever possible, provide professional services through in-network providers. This helps ensure that the services are covered by the patient’s insurance policy and reduces the likelihood of denial code 89.
- Pre-Authorization: Familiarize yourself with the pre-authorization requirements of the patient’s insurance policy. Obtain pre-authorization for any services that require it to avoid potential denials or reductions in payment.
- Clear Communication with Patients: Educate patients about their insurance coverage and any potential limitations or exclusions. Clearly communicate any financial responsibilities they may have for professional services and discuss alternative payment options if necessary.
5. Example Cases
Below are two examples of denial code 89:
- Example 1: A patient undergoes a cosmetic procedure that is not covered by their insurance policy. The insurance company denies payment for the professional fees associated with the procedure, resulting in denial code 89.
- Example 2: A provider submits a claim with an incorrect CPT code for a specific professional service. The insurance company denies or reduces payment for the services rendered due to the coding error, resulting in denial code 89.
