How To Fix Denial Code A6 | Common Reasons, Next Steps & How To Avoid It

Denial Code A6 means that a claim has been denied because the prior hospitalization or 30-day transfer requirement has not been met. Below you can find the description, common reasons for denial code A6, next steps, how to avoid it, and examples.

2. Description

Denial Code A6 is a Claim Adjustment Reason Code (CARC) and is described as ‘Prior hospitalization or 30-day transfer requirement not met’. This denial code indicates that the insurance company will not make the payment for the billed service because the patient did not meet the necessary criteria for hospitalization or transfer within the required timeframe. In simpler terms, the claim is not payable until the patient meets the specific requirements set by the insurance company.

2. Common Reasons

The most common reasons for denial code A6 are:

1. Lack of Prior Hospitalization: Denial code A6 is often triggered when a patient does not have a documented prior hospitalization within the specified timeframe. Insurance plans may require a certain number of days of hospitalization before covering certain services or procedures. If the patient does not meet this requirement, the claim will be denied.
2. Failure to Meet Transfer Requirement: Some insurance policies have specific transfer requirements, such as being transferred from one healthcare facility to another within a certain timeframe. If the patient fails to meet this transfer requirement, the claim may be denied under denial code A6.
3. Inadequate Documentation: Insufficient or incomplete documentation of prior hospitalization or transfer can lead to denial code A6. If the necessary medical records or transfer documentation are missing or do not meet the insurance company’s requirements, the claim may be denied.
4. Incorrect Coding: Errors in coding can also result in denial code A6. If the procedure or service is not coded correctly to indicate the prior hospitalization or transfer, the claim may be denied.
5. Missing or Inaccurate Information: Claims may be denied under denial code A6 if there is missing or inaccurate information related to the prior hospitalization or transfer. This can include missing dates, incorrect patient identifiers, or incomplete transfer documentation.

3. Next Steps

You can fix denial code A6 as follows:

1. Review Documentation: Start by reviewing the documentation related to the prior hospitalization or transfer. Ensure that all necessary medical records, transfer documentation, and coding are complete and accurate.
2. Resubmit Claim with Additional Information: If the denial was due to inadequate documentation, gather any missing or additional information required by the insurance company. This may include additional medical records, transfer documentation, or clarification of coding. Resubmit the claim with the additional information to challenge the denial.
3. Appeal the Denial: If you believe the denial was incorrect or unjustified, you have the option to appeal the decision. Follow the insurance company’s appeal process, providing any supporting documentation or evidence to support your case. Be sure to clearly explain why the prior hospitalization or transfer requirement was met.
4. Coordinate with Healthcare Providers: If the denial was due to a lack of prior hospitalization or transfer, coordinate with the patient’s healthcare providers to ensure that the necessary documentation is obtained and shared. This may involve obtaining medical records from previous hospitals or coordinating with transferring facilities to ensure all requirements are met.
5. Improve Documentation Practices: To avoid future denials under denial code A6, implement improved documentation practices. Ensure that all necessary documentation related to prior hospitalization or transfer is consistently and accurately recorded. Train staff on the importance of proper documentation and provide resources to support accurate coding and record-keeping.

4. How To Avoid It

You can prevent denial code A6 in the future as follows:

1. Understand Insurance Requirements: Familiarize yourself with the specific requirements set by each insurance company regarding prior hospitalization or transfer. Ensure that you have a clear understanding of the necessary criteria and timeframes.
2. Educate Patients: Communicate with patients about the importance of meeting the prior hospitalization or transfer requirements. Provide clear instructions and guidance on what documentation is needed and the timeframe in which it should be obtained.
3. Verify Information: Double-check all patient information, including dates of prior hospitalization or transfer, before submitting a claim. Ensure that the information is accurate and matches the documentation.
4. Improve Coding Accuracy: Train staff on proper coding practices to accurately indicate prior hospitalization or transfer. Regularly review and update coding guidelines to ensure compliance with insurance requirements.
5. Implement Quality Assurance Measures: Establish quality assurance measures to review claims before submission. This can help identify any potential issues or errors related to prior hospitalization or transfer requirements.

5. Example Cases

Below are two examples of denial code A6:

• Example 1: A patient undergoes a surgical procedure that requires a prior hospitalization of at least three days. However, the claim is denied under denial code A6 because the patient’s medical records do not indicate a prior hospitalization within the required timeframe.
• Example 2: A patient is transferred from one healthcare facility to another for specialized treatment. However, the claim is denied under denial code A6 because the transfer documentation does not meet the insurance company’s requirements.

Source: Claim Adjustment Reason Codes