Denial Code P21 means that payment has been denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. This denial code is specific to Property and Casualty Auto claims. In this article, we will explore the description of denial code P21, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide example cases.
2. Description
Denial Code P21 is a claim adjustment reason code that indicates payment denial based on the jurisdictional regulations or payment policies related to Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits. This denial code is specific to Property and Casualty Auto claims. If the adjustment is at the claim level, the payer must provide the Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) in the 835 transaction. If the adjustment is at the line level, the payer must include the Healthcare Policy Identification Segment (Loop 2110 Service Payment information REF) in the 835 transaction. Denial code P21 is used to indicate that the denial is based on the regulations and policies specific to MPC and/or PIP Benefits.
2. Common Reasons
The most common reasons for denial code P21 are:
- Jurisdictional Regulations: Denial code P21 may occur when the claim does not comply with the jurisdictional regulations related to Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits. This could include situations where the claim does not meet the specific requirements or limitations set by the jurisdiction.
- Payment Policies: Denial code P21 can also be triggered when the claim does not align with the payment policies established by the insurance company. This could include situations where the services provided are not covered under the MPC and/or PIP Benefits, or when the claim does not meet the documentation or coding requirements specified by the payer.
3. Next Steps
To resolve denial code P21, follow these next steps:
- Review Jurisdictional Regulations: Carefully review the jurisdictional regulations related to Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits. Ensure that the claim meets all the requirements and limitations specified by the jurisdiction. If there are any discrepancies, address them accordingly.
- Check Payment Policies: Verify the payment policies established by the insurance company. Ensure that the services provided are covered under the MPC and/or PIP Benefits. Review the documentation and coding requirements specified by the payer and make any necessary adjustments to the claim.
- Communicate with the Payer: If there are any uncertainties or disagreements regarding the denial, reach out to the payer for clarification. Discuss the specifics of the claim and inquire about any additional information or documentation that may be required to resolve the denial.
- Provide Additional Information: If requested by the payer, provide any additional information or documentation that supports the claim’s compliance with the jurisdictional regulations and payment policies. This may include medical records, accident reports, or any other relevant documentation.
- Resubmit the Claim: Once all necessary adjustments and clarifications have been made, resubmit the claim to the payer for reconsideration. Ensure that all the required information is accurately included in the claim submission.
4. How To Avoid It
To avoid denial code P21 in the future, follow these steps:
- Stay Updated on Jurisdictional Regulations: Regularly review and stay updated on the jurisdictional regulations related to Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits. Familiarize yourself with the specific requirements and limitations set by the jurisdiction to ensure compliance.
- Understand Payment Policies: Thoroughly understand the payment policies established by the insurance company. Be aware of the services covered under the MPC and/or PIP Benefits and the documentation or coding requirements specified by the payer. Ensure that claims are submitted accurately and in accordance with these policies.
- Proper Documentation and Coding: Maintain accurate and detailed documentation for all services provided. Ensure that the documentation supports the medical necessity and appropriateness of the services. Code the claims correctly, following the guidelines and requirements specified by the payer.
- Regular Training and Education: Provide regular training and education to your billing and administrative staff on the jurisdictional regulations, payment policies, and proper documentation and coding practices. Keep them informed about any updates or changes in these areas to ensure accurate claim submissions.
5. Example Cases
Here are two examples of denial code P21:
- Example 1: A healthcare provider submits a claim for medical services provided to a patient involved in a car accident. However, the claim is denied under denial code P21 because the services are not covered under the patient’s Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits.
- Example 2: A provider submits a claim for physical therapy sessions following a car accident. The claim is denied under denial code P21 because the documentation submitted does not meet the jurisdictional regulations regarding the medical necessity and appropriateness of the services.
