How To Fix Denial Code P18 | Common Reasons, Next Steps & How To Avoid It

Denial Code P18 means that the procedure billed is not listed in the jurisdiction fee schedule. However, an allowance has been made for a comparable service. It is important to note that this denial code is applicable only for Property and Casualty claims. Below you can find a detailed description of denial code P18, common reasons for its occurrence, next steps to resolve it, tips on how to avoid it in the future, and examples.

2. Description

Denial Code P18 is specific to Property and Casualty claims and is described as ‘Procedure is not listed in the jurisdiction fee schedule’. This means that the procedure code submitted for reimbursement is not included in the fee schedule approved by the jurisdiction. However, the insurance company has allowed an amount for a comparable service. In simpler terms, the claim is denied because the specific procedure code is not covered, but an alternative service may be eligible for reimbursement.

2. Common Reasons

The most common reasons for denial code P18 are:

1. Procedure Not Covered: Denial code P18 occurs when the specific procedure code billed is not included in the fee schedule approved by the jurisdiction. This could be due to the procedure being considered experimental, not medically necessary, or simply not covered under the insurance policy.
2. Incorrect Procedure Code: Sometimes, the denial may be a result of an error in coding. If the wrong procedure code is submitted, it may not match any covered services in the fee schedule, leading to denial code P18.
3. Out-of-Network Provider: If the provider is not in the network approved by the insurance company, the procedure may not be covered under the jurisdiction fee schedule. This can result in denial code P18.
4. Missing Documentation: Insufficient or missing documentation to support the medical necessity of the procedure can also lead to denial code P18. Without proper documentation, the insurance company may determine that the procedure is not eligible for reimbursement.

3. Next Steps

To resolve denial code P18, follow these steps:

1. Review Fee Schedule: Verify the jurisdiction fee schedule to determine if the specific procedure code is indeed not covered. Cross-reference the billed procedure code with the approved fee schedule to confirm the denial.
2. Check Coding Accuracy: Double-check the accuracy of the procedure code submitted. Ensure that the correct code is used and matches the service provided. If there was an error in coding, correct it and resubmit the claim.
3. Appeal with Documentation: If you believe the procedure should be covered, gather all necessary documentation to support the medical necessity of the service. This may include medical records, test results, or physician notes. Submit an appeal with the additional documentation to challenge the denial.
4. Contact Insurance Company: Reach out to the insurance company’s provider support to discuss the denial and seek clarification on the coverage of the procedure. They may provide insights or guidance on how to proceed.
5. Consider Alternative Service: If denial code P18 is due to the procedure not being covered, explore alternative services that are included in the fee schedule. Discuss with the patient and their healthcare provider to determine if an alternative service can be provided.

4. How To Avoid It

To avoid denial code P18 in the future, consider the following:

1. Verify Coverage: Before performing any procedure, verify the coverage with the insurance company. Ensure that the specific procedure code is listed in the jurisdiction fee schedule to avoid potential denials.
2. Accurate Coding: Use the correct procedure code when submitting claims. Regularly train and educate coding staff to ensure accurate coding practices.
3. Network Participation: If you are an out-of-network provider, consider joining the insurance company’s network to ensure that the procedures you perform are covered under the jurisdiction fee schedule.
4. Thorough Documentation: Maintain detailed and accurate documentation to support the medical necessity of the procedures performed. This will help in case of any future audits or denials.

5. Example Cases

Here are two examples of denial code P18:

• Example 1: A healthcare provider submits a claim for a specialized procedure that is not covered under the jurisdiction fee schedule. The claim is denied with denial code P18, but the insurance company allows an amount for a comparable service that is covered.
• Example 2: A provider mistakenly uses an incorrect procedure code when submitting a claim. As a result, the procedure is not listed in the jurisdiction fee schedule, leading to denial code P18.

Source: Claim Adjustment Reason Codes