How To Fix Denial Code B7 | Common Reasons, Next Steps & How To Avoid It

Denial Code B7 means that the provider was not certified or eligible to be paid for a specific procedure or service on a particular date of service. This denial code indicates that the claim has been denied due to the provider’s lack of certification or eligibility. In this article, we will explore the description of denial code B7, common reasons for its occurrence, next steps to resolve the denial, how to avoid it in the future, and provide examples of denial code B7 cases.

2. Description

Denial Code B7 is a specific Claim Adjustment Reason Code (CARC) that signifies that the provider was not certified or eligible to receive payment for a particular procedure or service on a specific date of service. This denial code is often accompanied by the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), which provides additional information about the policy or guideline that led to the denial. Denial code B7 indicates that the claim has been rejected due to the provider’s lack of certification or eligibility to perform the billed service.

2. Common Reasons

The most common reasons for denial code B7 are:

1. Lack of Certification: Providers may face denial code B7 if they do not possess the necessary certification or credentials to perform the specific procedure or service billed. Insurance companies require providers to meet certain qualifications and certifications to ensure the quality and safety of healthcare services.
2. Expired Certification: Denial code B7 can occur when a provider’s certification or eligibility has expired. Certifications often have an expiration date, and if the provider fails to renew or update their certification, claims for services performed after the expiration date may be denied.
3. Service Not Covered: Some insurance policies have specific guidelines regarding the coverage of certain procedures or services. If the billed service is not covered under the patient’s insurance policy, denial code B7 may be applied.
4. Incorrect Coding: Inaccurate coding of the procedure or service can lead to denial code B7. If the provider uses an incorrect or invalid code when submitting the claim, the insurance company may deny the claim due to the mismatch between the billed service and the provider’s certification or eligibility.
5. Lack of Preauthorization: Certain procedures or services require preauthorization from the insurance company before they can be performed. If the provider fails to obtain the necessary preauthorization, denial code B7 may be issued.

3. Next Steps

To resolve denial code B7, the following steps can be taken:

1. Review Certification Status: Verify the provider’s certification or eligibility status for the specific procedure or service that was denied. Check if the certification has expired or if there are any other issues that may have led to the denial.
2. Contact the Insurance Company: Reach out to the insurance company to understand the specific policy or guideline that led to the denial. Request clarification on the requirements for certification or eligibility and inquire about any necessary steps to rectify the situation.
3. Update Certification: If the denial was due to an expired certification, take the necessary steps to renew or update the certification. This may involve completing additional training, submitting updated documentation, or fulfilling any other requirements set by the certifying body.
4. Appeal the Denial: If the denial was issued in error or if there are valid reasons to challenge the denial, prepare a formal appeal. Gather supporting documentation, such as proof of certification or evidence of compliance with the insurance company’s guidelines, and submit the appeal according to the insurer’s procedures.
5. Seek Expert Assistance: If navigating the appeals process becomes challenging, consider seeking assistance from a healthcare billing or coding expert. They can provide guidance on the specific requirements and help prepare a strong appeal to overturn the denial.

4. How To Avoid It

To avoid denial code B7 in the future, consider the following measures:

1. Maintain Updated Certifications: Ensure that all providers within the practice maintain up-to-date certifications and credentials for the procedures or services they offer. Regularly monitor expiration dates and take the necessary steps to renew or update certifications in a timely manner.
2. Verify Coverage and Preauthorization: Before performing any procedure or service, verify the patient’s insurance coverage and check if preauthorization is required. Familiarize yourself with the insurance company’s guidelines and ensure compliance to avoid denials related to coverage or preauthorization.
3. Accurate Coding: Use accurate and valid codes when submitting claims. Regularly train billing and coding staff to stay updated on the latest coding guidelines and ensure that all codes accurately reflect the services provided.
4. Stay Informed: Keep abreast of any changes or updates in insurance policies, guidelines, or certification requirements. Regularly communicate with insurance companies to understand any modifications that may impact the provider’s certification or eligibility.

5. Example Cases

Here are two examples of denial code B7:

• Example 1: A provider submits a claim for a specialized surgical procedure that requires a specific certification. However, the provider’s certification for that procedure has expired, resulting in denial code B7.
• Example 2: A provider performs a service that is not covered under the patient’s insurance policy. As a result, the claim is denied with denial code B7.

Source: Claim Adjustment Reason Codes