How To Fix Denial Code P11 | Common Reasons, Next Steps & How To Avoid It

Denial Code P11 means that the disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. This code is specific to Property and Casualty claims and should only be used with Group Code OA. Below you can find the description, common reasons for denial code P11, next steps, how to avoid it, and examples.

2. Description

Denial Code P11 is a specific code used for Property and Casualty claims. It indicates that the disposition of the claim, which involves an injury or illness, is pending due to ongoing litigation. This means that the insurance company will not make a payment for the claim until the litigation is resolved. Denial Code P11 should only be used with Group Code OA.

2. Common Reasons

The most common reasons for denial code P11 are:

1. Ongoing Litigation: Denial Code P11 is triggered when there is ongoing legal action related to the Property and Casualty claim. This could be a result of disputes over liability, coverage, or other factors that require resolution through the legal process. Until the litigation is concluded, the insurance company will not make a payment for the claim.
2. Incorrect Use of Code: Denial Code P11 should only be used for Property and Casualty claims and with Group Code OA. If this code is used incorrectly for other types of claims or with different group codes, it can result in denials.
3. Deactivated Code: Denial Code P11 replaced a previously deactivated code, Code 255. If providers or billers continue to use the deactivated code instead of the updated P11 code, it will result in denials.

3. Next Steps

To address denial code P11, follow these next steps:

1. Confirm Litigation Status: Verify the current status of the litigation related to the claim. Contact the insurance company or legal representatives involved to gather information about the progress of the case and any expected timelines for resolution.
2. Communication with Legal Team: If you are the provider or biller, communicate with the legal team handling the litigation to understand the impact it may have on the claim. Discuss any necessary documentation or information that may be required to support the claim during the litigation process.
3. Documentation and Resubmission: If the denial was in error and the litigation has been resolved, gather all relevant documentation and evidence to support the claim. This may include court orders, settlement agreements, or any other legal documents that confirm the resolution of the litigation. Then, resubmit the claim with this additional documentation to challenge the denial.
4. Liaise with Insurance: If there is confusion or disagreement about the use of Denial Code P11, directly contact the insurance company’s provider support. Discuss the specifics of the claim and the rationale behind its denial. This can lead to a resolution or clarification on how to properly apply the code and process the claim.
5. Stay Updated: Keep track of the progress of the litigation and any updates from the insurance company or legal representatives. This will help ensure that the claim is processed correctly once the litigation is resolved.

4. How To Avoid It

To avoid denial code P11 in the future, follow these steps:

1. Understand the Code Usage: Familiarize yourself with the specific use of Denial Code P11 for Property and Casualty claims and with Group Code OA. Ensure that you only apply this code when it is appropriate and avoid using it for other types of claims or with different group codes.
2. Stay Informed: Stay updated on any changes or updates to the claim adjustment reason codes. This will help you avoid using deactivated codes and ensure that you are using the most current and accurate codes for claim submissions.
3. Proper Documentation: Maintain thorough and accurate documentation related to the claim and any ongoing litigation. This includes all relevant legal documents, correspondence, and evidence that may be required to support the claim during the litigation process.
4. Collaboration with Legal Team: If you are involved in the billing or claims process, establish effective communication and collaboration with the legal team handling the litigation. This will help ensure that all necessary information is shared and that the claim is processed correctly once the litigation is resolved.

5. Example Cases

Below are two examples of denial code P11:

• Example 1: A provider submits a claim for a personal injury case that is currently under litigation. The claim is denied with Denial Code P11, indicating that the disposition of the claim is pending due to ongoing legal action.
• Example 2: A biller mistakenly uses Denial Code P11 for a claim that is not related to Property and Casualty. The claim is denied because the code is not applicable to the type of claim being submitted.

Source: Claim Adjustment Reason Codes