Denial Code P24 means that the payment has been adjusted based on Preferred Provider Organization (PPO) regulations. This denial code is typically used in Property and Casualty cases and should be addressed according to the guidelines provided in the 835 Class of Contract Code Identification Segment or the 835 Healthcare Policy Identification Segment. In this article, we will explore the description of denial code P24, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples to illustrate its application.
2. Description
Denial Code P24 is a specific Claim Adjustment Reason Code (CARC) that indicates the payment adjustment based on PPO regulations. This code is used when the payer determines that the payment needs to be adjusted according to the terms and conditions of the PPO contract. It is important for providers to refer to 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, to understand the specific regulations that apply.
2. Common Reasons
The most common reasons for denial code P24 are:
- Contractual Obligations: Denial code P24 is often triggered when the payment adjustment is required due to contractual obligations outlined in the PPO agreement. This could include limitations on covered services, specific reimbursement rates, or other contractual terms that impact the payment amount.
- Out-of-Network Providers: PPO plans typically have a network of preferred providers, and if a patient seeks services from an out-of-network provider, the payment may be adjusted based on the PPO regulations. This can result in denial code P24 being applied to the claim.
- Incorrect Billing Information: In some cases, denial code P24 may be triggered due to errors or inaccuracies in the billing information submitted by the provider. This could include incorrect PPO contract codes or failure to provide the necessary documentation to support the claim.
- Non-Covered Services: PPO plans may have specific exclusions or limitations on certain services or procedures. If a claim includes a service that is not covered under the PPO contract, denial code P24 may be applied to indicate the payment adjustment.
3. Next Steps
To address denial code P24, providers should take the following steps:
- Review PPO Contract: Providers should carefully review the PPO contract to understand the specific regulations and contractual obligations that apply. This will help in determining the reason for the payment adjustment and guide the next steps.
- Verify Billing Information: Providers should double-check the accuracy of the billing information submitted for the claim. This includes ensuring that the correct PPO contract codes are used and that all necessary supporting documentation is included.
- Contact Payer: If there are any questions or concerns regarding the payment adjustment, providers should reach out to the payer for clarification. This can help in understanding the specific reasons for the adjustment and potentially resolve any discrepancies.
- Appeal if Applicable: If the provider believes that the payment adjustment was made in error or disagrees with the application of denial code P24, they may choose to appeal the decision. This typically involves providing additional documentation or evidence to support the claim.
4. How To Avoid It
To avoid denial code P24 in the future, providers should consider the following strategies:
- Verify PPO Participation: Before providing services to a patient, providers should verify their participation status with the PPO network. This will help ensure that the services will be covered under the PPO contract and minimize the likelihood of payment adjustments.
- Understand Contractual Obligations: Providers should thoroughly review the PPO contract and familiarize themselves with the specific regulations and limitations. This will help in accurately billing for services and avoiding non-covered procedures or services.
- Submit Accurate Billing Information: Providers should ensure that all billing information is accurate and complete. This includes using the correct PPO contract codes, providing necessary supporting documentation, and following any specific billing guidelines outlined in the PPO contract.
- Stay Updated: PPO contracts and regulations may change over time. Providers should stay informed about any updates or changes to the PPO contract to ensure compliance and accurate billing.
5. Example Cases
Here are two examples of denial code P24:
- Example 1: A provider submits a claim for a service that is not covered under the patient’s PPO contract. As a result, the payment is adjusted based on the PPO regulations, and denial code P24 is applied.
- Example 2: A provider mistakenly uses an incorrect PPO contract code when submitting a claim. The payer adjusts the payment based on the correct PPO contract, resulting in denial code P24.
