Denial Code P20 means that the service billed is not paid under the jurisdiction allowed outpatient facility fee schedule. This denial code is specific to Property and Casualty claims. In this article, we will provide a description of denial code P20, common reasons for its occurrence, next steps to resolve it, tips on how to avoid it in the future, and examples of cases where denial code P20 may be applied.
2. Description
Denial Code P20 is a specific Claim Adjustment Reason Code (CARC) that indicates the service billed is not eligible for payment under the jurisdiction allowed outpatient facility fee schedule. This denial code is applicable only to Property and Casualty claims. It was introduced on November 1, 2013, replacing the deactivated code W9.
2. Common Reasons
The most common reasons for denial code P20 are:
- Out-of-Network Providers: One common reason for denial code P20 is when the healthcare provider is not part of the insurance company’s approved network. Insurance plans often have specific networks of providers with whom they have negotiated rates. If a patient receives services from an out-of-network provider, the claim may be denied under denial code P20.
- Non-Covered Services: Denial code P20 may also be applied when the service provided is not covered under the patient’s insurance policy. Insurance plans have specific coverage limitations and exclusions, and if the service falls outside of these parameters, the claim may be denied.
- Incorrect Coding: Inaccurate coding can also lead to denial code P20. If the service is coded incorrectly, it may not align with the allowed outpatient facility fee schedule, resulting in the claim being denied.
- Missing or Incomplete Documentation: Insufficient or incomplete documentation can also trigger denial code P20. If the necessary documentation to support the billed service is missing or incomplete, the claim may be denied.
3. Next Steps
If you receive denial code P20, here are the next steps to resolve it:
- Review the Denial Explanation: Carefully review the explanation provided with the denial code. This will help you understand the specific reason for the denial and guide your next steps.
- Verify Network Participation: If the denial is due to the provider being out-of-network, confirm the patient’s insurance network and ensure that the services were provided by an in-network provider. If there was an error in network information, you may need to resubmit the claim with the correct details.
- Check Coverage Limitations: Review the patient’s insurance policy to determine if the service is covered. If the service is not covered, you may need to explore alternative payment options with the patient or discuss the possibility of appealing the denial.
- Review Coding Accuracy: Double-check the coding used for the service. Ensure that it aligns with the allowed outpatient facility fee schedule. If there was an error in coding, correct it and resubmit the claim.
- Complete Documentation: If the denial was due to missing or incomplete documentation, gather all necessary documentation to support the billed service. Ensure that the documentation is complete and accurate before resubmitting the claim.
- Appeal if Necessary: If you believe the denial was incorrect or unjustified, you have the option to appeal the decision. Follow the insurance company’s appeal process and provide any additional supporting documentation to strengthen your case.
4. How To Avoid It
To avoid denial code P20 in the future, consider the following tips:
- Verify Network Participation: Before providing services, confirm the patient’s insurance network and ensure that you are an in-network provider. If you are out-of-network, discuss alternative payment options with the patient upfront.
- Check Coverage Limitations: Familiarize yourself with the patient’s insurance policy and understand the coverage limitations and exclusions. This will help you determine if a service is covered before providing it.
- Ensure Accurate Coding: Take care to accurately code the services provided. Stay updated on coding guidelines and ensure that the codes align with the allowed outpatient facility fee schedule.
- Thorough Documentation: Maintain complete and accurate documentation for all services provided. This includes detailed notes, test results, and any other relevant information that supports the billed service.
5. Example Cases
Here are two examples of denial code P20:
- Example 1: A patient receives physical therapy from an out-of-network provider. The claim is denied under denial code P20 because the provider is not part of the patient’s insurance network.
- Example 2: A patient undergoes an elective cosmetic procedure that is not covered by their insurance policy. The claim is denied under denial code P20 due to the service being non-covered.
