How To Fix Denial Code P23 | Common Reasons, Next Steps & How To Avoid It

Denial Code P23 means that the claim has been denied due to a jurisdictional fee schedule adjustment for Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. In this article, we will provide a description of denial code P23, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code P23 cases.

2. Description

Denial Code P23 is a specific code used for Property and Casualty Auto claims. It indicates that the claim has been denied due to a jurisdictional fee schedule adjustment for Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. This adjustment is based on the regulations and guidelines set forth by the insurance company and the jurisdiction in which the claim is being processed. The payer will provide further information in the 835 Class of Contract Code Identification Segment or the 835 Healthcare Policy Identification Segment, depending on whether the adjustment is at the claim level or line level.

2. Common Reasons

The most common reasons for denial code P23 are:

1. Non-Compliance with Jurisdictional Fee Schedule: The claim may be denied if the billed amount exceeds the fee schedule set by the jurisdiction for Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. It is important for providers to ensure that their charges align with the fee schedule to avoid denials under code P23.
2. Missing or Incomplete Documentation: Insufficient or incomplete documentation can lead to denials under code P23. It is crucial for providers to submit all necessary supporting documentation to justify the billed charges and comply with the jurisdictional requirements.
3. Incorrect Coding: Incorrect coding of services rendered can result in denials under code P23. Providers should ensure accurate coding to align with the jurisdictional fee schedule and avoid discrepancies that may trigger a denial.
4. Lack of Prior Authorization: Some jurisdictions may require prior authorization for certain services covered under Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. Failure to obtain prior authorization can lead to denials under code P23.

3. Next Steps

To resolve denial code P23, follow these next steps:

1. Review Jurisdictional Fee Schedule: Verify the fee schedule set by the jurisdiction for Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. Ensure that the billed charges comply with the fee schedule to address the denial.
2. Check Documentation: Review the submitted documentation to ensure it is complete and supports the billed charges. If any documentation is missing or incomplete, gather the necessary information and resubmit the claim with the updated documentation.
3. Correct Coding Errors: If the denial was due to coding errors, correct the coding and resubmit the claim with the accurate codes that align with the jurisdictional fee schedule.
4. Obtain Prior Authorization: If prior authorization is required for the services rendered, ensure that the necessary authorization is obtained and submit the claim with the proper documentation.
5. Contact the Payer: If there is confusion or disagreement regarding the denial, contact the payer’s provider support to discuss the specifics of the claim and seek clarification on the denial reason. This communication can help resolve any misunderstandings and provide guidance on how to address the denial.

4. How To Avoid It

To avoid denial code P23 in the future, consider the following tips:

1. Stay Updated on Jurisdictional Fee Schedules: Regularly review and stay informed about the fee schedules set by the jurisdiction for Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. Ensure that your charges align with the fee schedule to minimize the risk of denials under code P23.
2. Thorough Documentation: Maintain thorough and complete documentation for all services rendered. Ensure that the documentation supports the billed charges and complies with the jurisdictional requirements. This will help prevent denials due to missing or incomplete documentation.
3. Accurate Coding: Pay close attention to accurate coding of services. Ensure that the codes used align with the jurisdictional fee schedule and accurately reflect the services provided. Regularly train your coding staff to stay updated on coding guidelines and best practices.
4. Prior Authorization: Familiarize yourself with the jurisdiction’s requirements for prior authorization. Ensure that you obtain the necessary authorizations before providing services covered under Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. This will help avoid denials related to lack of prior authorization.

5. Example Cases

Here are two examples of denial code P23:

• Example 1: A provider submits a claim for medical services covered under Personal Injury Protection (PIP) Benefits. However, the billed charges exceed the fee schedule set by the jurisdiction. As a result, the claim is denied under code P23.
• Example 2: A provider fails to obtain prior authorization for a surgical procedure covered under Medical Payments Coverage (MPC). The claim is subsequently denied under code P23 due to the lack of prior authorization.

Source: Claim Adjustment Reason Codes