How To Fix Denial Code P16 | Common Reasons, Next Steps & How To Avoid It

Denial Code P16 means that the medical provider is not authorized or certified to provide treatment to injured workers in a specific jurisdiction. This denial code is specific to Workers’ Compensation claims and should be used with Group Code CO or OA. It is important to understand the common reasons for denial code P16, the next steps to take when faced with this denial, how to avoid it in the future, and examples of cases where denial code P16 may be applied.

2. Description

Denial Code P16 is a specific denial code that indicates the medical provider is not authorized or certified to provide treatment to injured workers in a particular jurisdiction. This denial code is applicable only to Workers’ Compensation claims and should be used with Group Code CO or OA. It is important to note that this denial code replaced the previously deactivated code W5 and has been in effect since November 1, 2013.

2. Common Reasons

The most common reasons for denial code P16 are:

1. Lack of Authorization/Certification: The medical provider may not have the necessary authorization or certification to provide treatment to injured workers in the specific jurisdiction. This could be due to expired credentials, failure to meet the jurisdiction’s requirements, or other administrative issues.
2. Incorrect Group Code: Denial code P16 should be used with Group Code CO or OA. If the incorrect group code is used, it may result in the claim being denied under a different denial code or not being processed correctly.
3. Non-Compliance with Workers’ Compensation Regulations: The medical provider may not be in compliance with the specific regulations and requirements set forth by the Workers’ Compensation system in the jurisdiction. This could include failure to submit necessary documentation, failure to follow proper billing procedures, or other non-compliance issues.

3. Next Steps

If you receive a denial with code P16, it is important to take the following steps:

1. Review Authorization/Certification Status: Verify the authorization or certification status of the medical provider in the specific jurisdiction. Ensure that all necessary credentials are up to date and in compliance with the Workers’ Compensation system requirements.
2. Check Group Code: Double-check that the correct Group Code CO or OA is used when submitting the claim. Using the incorrect group code can result in the claim being denied or processed incorrectly.
3. Contact the Insurance Company: Reach out to the insurance company to discuss the denial and gather more information about the specific reason for the denial. This can help identify any additional steps or requirements that need to be fulfilled.
4. Rectify Compliance Issues: If the denial is due to non-compliance with Workers’ Compensation regulations, take the necessary steps to rectify the compliance issues. This may involve submitting additional documentation, updating billing procedures, or addressing any other non-compliance issues.
5. Resubmit the Claim: Once the necessary steps have been taken to address the denial reason, resubmit the claim with the correct information and documentation. Ensure that all requirements are met and that the claim is accurately coded and billed.

4. How To Avoid It

To avoid denial code P16 in the future, consider the following:

1. Verify Authorization/Certification: Before providing treatment to injured workers, verify that the medical provider has the necessary authorization or certification in the specific jurisdiction. Stay updated on any changes in requirements or expiration dates.
2. Use Correct Group Code: When submitting Workers’ Compensation claims, ensure that the correct Group Code CO or OA is used. This will help ensure that the claim is processed correctly and minimize the risk of denial under a different code.
3. Stay Compliant with Regulations: Familiarize yourself with the Workers’ Compensation regulations and requirements in the jurisdiction where you provide services. Stay compliant with documentation, billing procedures, and any other regulations to avoid denials due to non-compliance.

5. Example Cases

Here are two examples of denial code P16:

• Example 1: A medical provider submits a Workers’ Compensation claim for treatment provided to an injured worker in a specific jurisdiction. However, the provider’s certification to provide treatment in that jurisdiction has expired. As a result, the claim is denied under denial code P16.
• Example 2: A medical provider mistakenly uses the incorrect Group Code when submitting a Workers’ Compensation claim. Instead of using Group Code CO or OA, they use a different code. The claim is subsequently denied under a different denial code, leading to confusion and potential delays in payment.

Source: Claim Adjustment Reason Codes