Denial Code P26 means that the payment has been adjusted based on Voluntary Provider network (VPN). This denial code is typically used in Property and Casualty cases. In this article, we will explore the description of denial code P26, 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 P26 is a payment adjustment code that indicates the payment has been adjusted based on Voluntary Provider network (VPN). This code is specific to Property and Casualty cases. If the adjustment is at the claim level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If the adjustment is at the line level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (Loop 2110 Service Payment Information REF) if the regulations apply.
2. Common Reasons
The most common reasons for denial code P26 are:
- Out-of-Network Providers: Denial code P26 often occurs when a patient seeks treatment from a provider who is not part of the Voluntary Provider network (VPN) specified by their insurance plan. Insurance companies may adjust the payment based on the terms of the network agreement, resulting in a denial for the provider.
- Incorrect Billing Information: In some cases, denial code P26 may occur due to errors in the billing information submitted by the provider. This could include incorrect VPN codes or failure to include the necessary information to indicate the use of the Voluntary Provider network.
- Lack of Authorization: Insurance plans may require prior authorization for certain services or treatments. If the provider fails to obtain the necessary authorization, the payment may be adjusted based on the Voluntary Provider network, resulting in a denial under code P26.
- Non-Covered Services: Denial code P26 may also be triggered when the services provided are not covered under the patient’s insurance plan. In such cases, the payment may be adjusted based on the Voluntary Provider network, leading to a denial for the provider.
3. Next Steps
To resolve denial code P26, follow these next steps:
- Review the Explanation of Benefits (EOB): Carefully review the EOB provided by the insurance company to understand the specific reason for the denial under code P26. This will help identify the exact issue that needs to be addressed.
- Contact the Insurance Company: Reach out to the insurance company’s provider support to discuss the denial and seek clarification on the adjustment based on the Voluntary Provider network. Provide any necessary documentation or information to support your case.
- Verify Billing Information: Double-check the billing information submitted for accuracy. Ensure that the VPN codes and any other required information related to the Voluntary Provider network are included correctly.
- Obtain Authorization if Required: If the denial is due to a lack of authorization, work with the patient and insurance company to obtain the necessary authorization for the services provided. Submit the required documentation to support the authorization request.
- Appeal the Denial: If you believe the denial under code P26 is incorrect or unjustified, prepare an appeal with supporting documentation. This may include evidence of network participation, correct billing information, or proof of authorization if applicable.
4. How To Avoid It
To avoid denial code P26 in the future, consider the following steps:
- Verify Network Participation: Before providing services to a patient, verify their insurance coverage and ensure that you are a participating provider in the Voluntary Provider network specified by their plan. If you are not part of the network, discuss alternative options with the patient.
- Accurate Billing Information: Pay close attention to the billing information submitted. Ensure that the VPN codes and any other required information related to the Voluntary Provider network are included accurately.
- Obtain Authorization: Familiarize yourself with the insurance plan’s authorization requirements. Obtain the necessary authorizations for services that require prior approval to avoid denials based on the Voluntary Provider network.
- Stay Informed: Regularly review updates and changes to the Voluntary Provider network agreements. Stay informed about any modifications to the network and ensure that you are aware of the services covered under the network.
5. Example Cases
Here are two examples of denial code P26:
- Example 1: A patient seeks treatment from a specialist who is not part of their insurance plan’s Voluntary Provider network. As a result, the payment is adjusted based on the network agreement, leading to a denial under code P26.
- Example 2: A provider submits a claim without including the necessary VPN codes to indicate the use of the Voluntary Provider network. The insurance company adjusts the payment based on the network agreement, resulting in a denial under code P26.
