How To Fix Denial Code P28 | Common Reasons, Next Steps & How To Avoid It

Denial Code P28 means that the payment has been adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. This code is typically used for Property and Casualty Auto claims. In this article, we will explore the description of Denial Code P28, 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 P28 is a specific Claim Adjustment Reason Code (CARC) that indicates the payment adjustment based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. This code is primarily used in Property and Casualty Auto claims. If the adjustment is at the claim level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) if the jurisdictional regulation applies. 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 P28 are:

1. Jurisdictional Regulations: Denial Code P28 may occur when the claim does not comply with the specific jurisdictional regulations related to Liability Coverage Benefits. This could include requirements for coverage limits, policy exclusions, or other regulations set by the governing authority.
2. Payment Policy Non-Compliance: If the claim does not adhere to the payment policies set by the insurance company, Denial Code P28 may be applied. This could include failure to provide necessary documentation, incorrect coding, or other non-compliance issues.
3. Property and Casualty Auto Claims Only: Denial Code P28 is specific to Property and Casualty Auto claims. If the claim falls under a different category, this denial code would not be applicable.

3. Next Steps

To resolve Denial Code P28, the following steps can be taken:

1. Review Jurisdictional Regulations: Carefully examine the jurisdictional regulations related to Liability Coverage Benefits for the specific claim. Ensure that the claim complies with all the requirements set by the governing authority.
2. Check Payment Policies: Verify that the claim adheres to the payment policies established by the insurance company. Review the documentation, coding, and any other requirements specified by the insurer.
3. Contact the Payer: If there is any confusion or disagreement regarding the denial, reach out to the payer for clarification. Discuss the specifics of the claim and inquire about the reasons for the denial. This communication can help identify any misunderstandings or provide guidance on how to address the denial.
4. Resubmit the Claim: If it is determined that the denial was in error or there are additional supporting documents, prepare the necessary documentation and resubmit the claim. Include any relevant information that demonstrates compliance with jurisdictional regulations and payment policies.
5. Seek Legal Advice: In complex cases involving jurisdictional regulations and liability coverage benefits, it may be beneficial to consult with legal professionals who specialize in insurance law. They can provide guidance on navigating the specific regulations and help resolve any disputes.

4. How To Avoid It

To avoid Denial Code P28 in the future, consider the following measures:

1. Stay Updated on Jurisdictional Regulations: Regularly review and stay informed about the jurisdictional regulations related to Liability Coverage Benefits. Keep track of any changes or updates that may impact claim submissions.
2. Comply with Payment Policies: Familiarize yourself with the payment policies set by the insurance company. Ensure that all claims are submitted in accordance with these policies, including proper documentation, accurate coding, and any other requirements specified by the insurer.
3. Double-Check Claim Information: Before submitting a claim, thoroughly review all the information provided. Check for any errors or omissions that could lead to a denial. Pay close attention to details such as policy numbers, coverage limits, and any specific requirements for Property and Casualty Auto claims.
4. Seek Professional Assistance: If you are unsure about any aspect of the claim submission process, consider seeking assistance from professionals who specialize in insurance claims. They can provide guidance and ensure that all necessary information is included to avoid denials.

5. Example Cases

Here are two examples of Denial Code P28:

• Example 1: A healthcare provider submits a claim for an auto accident injury treatment. However, the claim does not comply with the specific Liability Coverage Benefits regulations set by the governing authority. As a result, the claim is denied under Denial Code P28.
• Example 2: In another scenario, a provider fails to include the required documentation for a Property and Casualty Auto claim. The claim is denied under Denial Code P28 due to non-compliance with the payment policies set by the insurance company.

Source: Claim Adjustment Reason Codes