How To Fix Denial Code P6 | Common Reasons, Next Steps & How To Avoid It

Denial Code P6 means that the adjustment is based on entitlement to benefits. This code is typically used in Property and Casualty cases. In this article, we will explore the description of Denial Code P6, 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 P6 is an adjustment code that indicates the denial or adjustment of a claim based on entitlement to benefits. This code is specific to Property and Casualty cases. When this code is used, the payer is required to send additional information to the provider, such as the Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) or the Healthcare Policy Identification Segment (Loop 2110 Service Payment information REF) in the 835 transaction. Providers should refer to these segments for jurisdictional regulations and guidelines related to the denial or adjustment.

2. Common Reasons

The most common reasons for Denial Code P6 are:

1. Entitlement Issues: Denial Code P6 may occur when there are issues with the patient’s entitlement to benefits. This could include situations where the patient’s coverage has expired, the services rendered are not covered under the policy, or there are discrepancies in the policy details.
2. Missing or Incomplete Information: If the necessary information, such as the Insurance Policy Number or Healthcare Policy Identification, is missing or incomplete in the claim submission, the payer may use Denial Code P6 to indicate that the claim cannot be processed without the required information.
3. Jurisdictional Regulations: Denial Code P6 may be used when the denial or adjustment is based on jurisdictional regulations specific to Property and Casualty cases. These regulations may vary depending on the state or region, and the payer must provide the necessary information for the provider to understand the reason for the denial or adjustment.

3. Next Steps

To resolve Denial Code P6, the following steps can be taken:

1. Review the Denial Explanation: Carefully review the denial explanation provided by the payer. This will help identify the specific reason for the denial or adjustment and provide guidance on the next steps to take.
2. Contact the Payer: If the denial or adjustment is unclear or further clarification is needed, contact the payer’s provider support. Discuss the specific details of the claim and request additional information or guidance on how to proceed.
3. Verify Policy Details: Verify the patient’s policy details, including coverage dates, policy limits, and any specific requirements or exclusions. Ensure that the services rendered are covered under the policy and that all necessary information is included in the claim submission.
4. Resubmit the Claim: If the denial or adjustment was due to missing or incomplete information, resubmit the claim with the required information included. Ensure that all necessary segments, such as the Insurance Policy Number Segment or Healthcare Policy Identification Segment, are properly completed.
5. Follow Jurisdictional Regulations: If the denial or adjustment is based on jurisdictional regulations, refer to the 835 transaction for the specific information provided by the payer. Familiarize yourself with the regulations applicable to the case and ensure compliance in future claim submissions.

4. How To Avoid It

To avoid Denial Code P6 in the future, consider the following steps:

1. Verify Coverage Eligibility: Before providing services, verify the patient’s coverage eligibility and ensure that the services to be rendered are covered under the policy. This can help prevent denials or adjustments based on entitlement issues.
2. Submit Complete and Accurate Information: Ensure that all necessary information is included in the claim submission, including the Insurance Policy Number or Healthcare Policy Identification. Double-check the accuracy of the information to avoid denials or adjustments due to missing or incomplete data.
3. Stay Updated on Jurisdictional Regulations: Stay informed about the jurisdictional regulations specific to Property and Casualty cases in your state or region. Regularly review any updates or changes to these regulations to ensure compliance in claim submissions.

5. Example Cases

Here are two examples of Denial Code P6:

• Example 1: A patient’s auto insurance policy only covers medical expenses resulting from accidents. If a claim is submitted for a non-accident-related medical service, it may be denied under Denial Code P6, indicating that the service is not covered under the policy.
• Example 2: A provider submits a claim without including the required Insurance Policy Number segment in the 835 transaction. The payer denies the claim under Denial Code P6, indicating that the necessary information is missing for processing the claim.

Source: Claim Adjustment Reason Codes