How To Fix Denial Code B15 | Common Reasons, Next Steps & How To Avoid It

Denial Code B15 means that the service or procedure being billed requires a qualifying service or procedure to be received and covered. However, the qualifying other service or procedure has not been received or adjudicated. This denial code indicates that the claim cannot be processed until the necessary qualifying service or procedure has been completed and covered. Below you can find a detailed description of denial code B15, common reasons for its occurrence, next steps to resolve it, tips on how to avoid it in the future, and examples of cases involving denial code B15.

2. Description

Denial Code B15 is a specific claim adjustment reason code (CARC) that signifies the requirement of a qualifying service or procedure for the billed service. It indicates that the claim cannot be processed because the necessary qualifying service or procedure has not been received or adjudicated. This denial code is often used in healthcare policy identification segments (loop 2110 Service Payment Information REF) within the 835 transaction. It is essential to refer to this segment for further details if present.

2. Common Reasons

The most common reasons for denial code B15 are:

1. Missing Qualifying Service/Procedure: Denial code B15 may occur when the billed service or procedure requires a specific qualifying service or procedure to be completed and covered. If the qualifying service or procedure has not been received or adjudicated, the claim will be denied under this code.
2. Incomplete Documentation: Insufficient or incomplete documentation can lead to denial code B15. If the necessary documentation supporting the completion and coverage of the qualifying service or procedure is missing, the claim may be denied until the required documentation is provided.
3. Incorrect Coding: Incorrect coding of the billed service or procedure and the associated qualifying service or procedure can result in denial code B15. If the codes do not align or if there are coding errors, the claim may be denied until the coding discrepancies are resolved.
4. Lack of Medical Necessity: Denial code B15 may be triggered if the insurance company determines that the billed service or procedure and the associated qualifying service or procedure are not medically necessary. In such cases, the claim will be denied until the medical necessity is established.
5. Non-Covered Service/Procedure: If the qualifying service or procedure is not covered by the insurance policy, denial code B15 may be applied. The claim will be denied until the necessary qualifying service or procedure is covered or an alternative approach is taken.

3. Next Steps

To resolve denial code B15, follow these next steps:

1. Review Claim and Documentation: Thoroughly review the claim and associated documentation to identify any missing or incomplete information. Ensure that all necessary documentation supporting the completion and coverage of the qualifying service or procedure is included.
2. Verify Qualifying Service/Procedure: Confirm that the required qualifying service or procedure has been received and adjudicated. If it has not, take the necessary steps to complete the qualifying service or procedure and ensure it is covered.
3. Correct Coding Errors: If coding errors are identified, correct them to ensure that the billed service or procedure and the associated qualifying service or procedure are accurately coded. This will help prevent further denials under code B15.
4. Establish Medical Necessity: If the insurance company questions the medical necessity of the billed service or procedure and the associated qualifying service or procedure, provide additional documentation or clarification to establish the medical necessity. Consult with the healthcare provider if necessary.
5. Explore Coverage Alternatives: If the qualifying service or procedure is not covered by the insurance policy, explore alternative approaches or services that may be covered. Discuss potential options with the healthcare provider and the insurance company to find a resolution.
6. Resubmit the Claim: Once all necessary steps have been taken, resubmit the claim with the corrected information, complete documentation, and any additional supporting evidence. Ensure that the claim accurately reflects the completion and coverage of the qualifying service or procedure.

4. How To Avoid It

To avoid denial code B15 in the future, consider the following tips:

1. Understand Coverage Requirements: Familiarize yourself with the insurance policy’s coverage requirements and the need for qualifying services or procedures. Ensure that you have a clear understanding of what is necessary for a claim to be processed successfully.
2. Document Thoroughly: Maintain comprehensive and accurate documentation for all services and procedures, including the qualifying service or procedure. Ensure that the documentation clearly supports the completion and coverage of the qualifying service or procedure.
3. Code Correctly: Pay close attention to coding guidelines and accurately assign the appropriate codes for the billed service or procedure and the associated qualifying service or procedure. Regularly update your coding knowledge to stay current with any changes or updates.
4. Verify Medical Necessity: Before submitting a claim, verify the medical necessity of the billed service or procedure and the associated qualifying service or procedure. Ensure that the services are justified and supported by appropriate medical documentation.
5. Check Coverage Limitations: Review the insurance policy for any limitations or exclusions related to the qualifying service or procedure. If it is not covered, consider alternative approaches or services that may be covered.

5. Example Cases

Here are two examples of denial code B15:

• Example 1: A healthcare provider submits a claim for a surgical procedure that requires a pre-operative consultation as a qualifying service. However, the pre-operative consultation was not received or adjudicated, resulting in denial code B15.
• Example 2: A claim is submitted for a specialized diagnostic test that requires a specific diagnostic procedure as a qualifying service. However, the diagnostic procedure was not completed or covered, leading to denial code B15.

Source: Claim Adjustment Reason Codes