How To Fix Denial Code B16 | Common Reasons, Next Steps & How To Avoid It

Denial Code B16 means that a claim has been denied because the qualifications for a new patient were not met. Below you can find the description, common reasons for denial code B16, next steps, how to avoid it, and examples.

2. Description

Denial Code B16 is a Claim Adjustment Reason Code (CARC) and is described as ‘New Patient’ qualifications were not met’. This denial code indicates that the claim has been denied because the patient does not meet the requirements to be considered a new patient. Insurance companies often have specific criteria that must be met for a patient to be classified as a new patient, such as not having received any services from the provider within a certain time frame.

2. Common Reasons

The most common reasons for denial code B16 are:

1. Patient History: Denial code B16 may occur if the patient has received services from the same provider within the defined time period that classifies them as a new patient. Insurance companies typically have guidelines on how long a patient must not have received services from a provider to be considered new, and if this criteria is not met, the claim may be denied.
2. Incorrect Coding: Another common reason for denial code B16 is incorrect coding. If the provider or billing staff incorrectly codes the claim as a new patient visit when the patient does not meet the qualifications, the claim may be denied under this code.
3. Lack of Documentation: Insufficient documentation to support the claim as a new patient visit can also lead to denial code B16. Insurance companies may require specific documentation, such as a new patient registration form or proof of the patient’s history with the provider, to classify a visit as a new patient visit.
4. Policy Limitations: Some insurance policies have limitations on the number of times a patient can be considered a new patient within a certain time frame. If the patient has already reached this limit, the claim may be denied under denial code B16.

3. Next Steps

You can address denial code B16 by following these steps:

1. Review Patient History: Verify the patient’s history with the provider to determine if they meet the qualifications to be considered a new patient. Check if the patient has received services from the same provider within the defined time frame.
2. Correct Coding: Ensure that the claim is coded correctly. If the patient does not meet the qualifications for a new patient visit, the claim should be coded accordingly to reflect the appropriate visit type.
3. Provide Documentation: If the patient does meet the qualifications for a new patient visit, ensure that the necessary documentation is included with the claim. This may include a new patient registration form or any other documentation required by the insurance company to support the claim.
4. Appeal the Denial: If the claim is denied under denial code B16 and you believe it was in error, you can appeal the denial. Provide any additional documentation or information that supports the claim as a new patient visit and submit it as part of the appeal process.
5. Communicate with the Patient: Keep the patient informed about the denial and the steps being taken to address it. If necessary, discuss alternative payment options or rescheduling the visit if the claim is not resolved in a timely manner.

4. How To Avoid It

To avoid denial code B16 in the future, consider the following:

1. Educate Staff: Ensure that your billing and administrative staff are familiar with the criteria for classifying a patient as a new patient. Provide training on how to accurately code claims and document new patient visits.
2. Verify Patient History: Before submitting a claim, verify the patient’s history with the provider to determine if they meet the qualifications for a new patient visit. If they do not, code the claim accordingly.
3. Document New Patient Visits: Keep thorough documentation of new patient visits, including any required forms or supporting documentation. This will help support the claim in case of an audit or denial.
4. Review Insurance Policies: Familiarize yourself with the limitations and requirements of the insurance policies you work with. Understand any restrictions on new patient visits and ensure that claims are submitted in accordance with these policies.

5. Example Cases

Below are two examples of denial code B16:

• Example 1: A patient visits a new healthcare provider for the first time. However, the patient had received services from the same provider within the past six months. The claim for the visit is denied under denial code B16 because the patient does not meet the qualifications for a new patient.
• Example 2: A patient visits a provider who is considered out-of-network for their insurance plan. The patient has never received services from this provider before. The claim is denied under denial code B16 because the provider is not in-network, and therefore, the patient does not meet the qualifications for a new patient visit.

Source: Claim Adjustment Reason Codes