How To Fix Denial Code B11 | Common Reasons, Next Steps & How To Avoid It

Denial Code B11 means that the claim or service has been transferred to the proper payer or processor for processing because it is not covered by the current payer or processor. In this article, we will provide a detailed description of denial code B11, common reasons for its occurrence, next steps to resolve it, tips on how to avoid it in the future, and examples of cases related to denial code B11.

2. Description

Denial Code B11 is a claim adjustment reason code (CARC) that indicates the claim or service has been transferred to the appropriate payer or processor for processing. This denial code is used when the current payer or processor determines that they are not responsible for covering the claim or service. It signifies that the claim/service is not covered by the current payer or processor, and it needs to be forwarded to the correct entity for further processing and potential payment.

2. Common Reasons

The most common reasons for denial code B11 are:

1. Out-of-Network Providers: Denial code B11 often occurs when the healthcare provider is not in the network of the current payer or processor. If the provider does not have a contract or agreement with the payer or processor, they may not be responsible for covering the claim or service.
2. Incorrect Payer or Processor: Sometimes, denial code B11 is triggered due to an error in the submission of the claim. The claim may have been sent to the wrong payer or processor, resulting in the denial. It is crucial to ensure that the claim is directed to the correct entity for processing.
3. Non-Covered Services: Denial code B11 may also occur when the specific service or procedure is not covered by the current payer or processor. Each payer or processor has its own set of covered services, and if the service falls outside of their coverage guidelines, the claim will be denied under denial code B11.
4. Expired or Inactive Insurance: If the patient’s insurance policy has expired or is inactive at the time of service, the claim may be denied under denial code B11. It is essential to verify the patient’s insurance coverage and ensure it is active before providing any services.
5. Policy Limitations: Some insurance policies have limitations on certain services or procedures. If the claim exceeds the policy’s coverage limits, it may be denied under denial code B11. It is crucial to review the patient’s policy and understand any limitations or restrictions that may apply.

3. Next Steps

To resolve denial code B11, follow these next steps:

1. Verify Payer or Processor: Confirm that the claim was indeed sent to the correct payer or processor. Check the information provided on the claim form and compare it with the payer or processor’s details. If there was an error in the submission, correct it and resubmit the claim to the appropriate entity.
2. Review Coverage Guidelines: Evaluate the coverage guidelines of the current payer or processor to determine if the service or procedure is indeed not covered. If it is a non-covered service, consider alternative options for reimbursement, such as patient self-pay or exploring other insurance coverage if applicable.
3. Contact the Payer or Processor: If there is uncertainty about the denial or if the claim should be covered, reach out to the payer or processor for clarification. Discuss the specifics of the claim and provide any necessary supporting documentation to support the claim’s validity. This communication can help resolve any misunderstandings or errors that led to the denial.
4. Appeal the Denial: If it is determined that the claim should be covered by the current payer or processor, prepare an appeal. Gather all relevant documentation, including medical records, policy information, and any other supporting evidence. Follow the appeal process outlined by the payer or processor to challenge the denial and seek reimbursement.
5. Update Billing Practices: To avoid future denials under code B11, ensure that billing practices are accurate and up to date. Double-check the payer or processor information before submitting claims and regularly review coverage guidelines to ensure services are eligible for reimbursement.

4. How To Avoid It

To prevent denial code B11 in the future, consider the following tips:

1. Verify Network Participation: Before providing services, confirm that the healthcare provider is in-network with the patient’s insurance plan. If the provider is out-of-network, inform the patient about potential out-of-pocket costs or explore alternative in-network options.
2. Double-Check Payer or Processor Information: Ensure that the claim is submitted to the correct payer or processor. Review the claim form for accuracy, including the payer or processor’s name, address, and any specific identifiers required for proper routing.
3. Understand Coverage Guidelines: Familiarize yourself with the coverage guidelines of the current payer or processor. Stay updated on any changes or updates to the policy to ensure that services provided align with the coverage criteria.
4. Verify Insurance Coverage: Before rendering services, verify the patient’s insurance coverage. Confirm that the policy is active and in effect on the date of service. If there are any issues with the insurance, communicate with the patient to resolve them before proceeding with treatment.
5. Educate Patients: Help patients understand their insurance coverage, including any limitations or exclusions. Clearly communicate the potential out-of-pocket costs associated with non-covered services to manage their expectations and avoid surprises.

5. Example Cases

Here are two examples of denial code B11:

• Example 1: A patient visits a specialist for a specific procedure. However, the specialist is not in-network with the patient’s insurance plan. As a result, the claim is denied under denial code B11, indicating that the service is not covered by the current payer or processor.
• Example 2: A healthcare provider accidentally submits a claim to the wrong insurance company. The claim is denied under denial code B11 since it was not received by the correct payer or processor. The provider realizes the error and resubmits the claim to the appropriate entity for processing.

Source: Claim Adjustment Reason Codes