How To Fix Denial Code P8 | Common Reasons, Next Steps & How To Avoid It

Denial Code P8 means that a claim is under investigation. This code is used when the payer needs to further review the claim before making a payment. In this article, we will explore the description of denial code P8, 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 P8 is used when a claim is under investigation. It indicates that the payer needs additional information or review before making a payment. This code is typically used in Property and Casualty cases. If the adjustment is at the claim level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment for jurisdictional regulations. If the adjustment is at the line level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment. Denial Code P8 is a replacement for the deactivated code 221.

2. Common Reasons

The most common reasons for denial code P8 are:

1. Incomplete Documentation: The claim may be missing necessary documentation or information required for the payer to process it. This could include medical records, supporting documentation, or other relevant details that are needed to evaluate the claim.
2. Policy Verification: The payer may need to verify the policy details or coverage information before making a payment. This could involve confirming the policyholder’s eligibility, coverage limits, or other policy-specific requirements.
3. Investigation Required: Certain claims may trigger an investigation due to suspected fraud, billing errors, or other irregularities. The payer may need to gather additional information, conduct interviews, or review supporting evidence to determine the validity of the claim.
4. Jurisdictional Regulations: In some cases, denial code P8 may be used to indicate that the claim is subject to specific jurisdictional regulations. The payer may require additional information or documentation to comply with these regulations before processing the claim.

3. Next Steps

To resolve denial code P8, the following steps can be taken:

1. Contact the Payer: Reach out to the payer to understand the specific reason for the investigation and gather any additional information or documentation they require. This will help expedite the review process and provide clarity on what is needed to move forward.
2. Provide Documentation: If the claim is missing any necessary documentation, ensure that it is promptly submitted to the payer. This may include medical records, invoices, or any other supporting evidence that can help validate the claim.
3. Cooperate with Investigation: If the claim is under investigation, cooperate fully with the payer’s requests for information or interviews. Provide any requested documentation or evidence promptly and accurately to assist in the investigation process.
4. Follow Up Regularly: Stay in touch with the payer to check on the progress of the investigation and to ensure that all necessary steps are being taken to resolve the claim. Regular communication can help expedite the process and address any concerns or questions that may arise.

4. How To Avoid It

To avoid denial code P8 in the future, consider the following steps:

1. Complete and Accurate Documentation: Ensure that all necessary documentation is included with the claim submission. Double-check that all required information is provided, including medical records, invoices, and any other supporting evidence.
2. Verify Policy Details: Before submitting a claim, verify the policy details and coverage information to ensure that it aligns with the services being billed. Confirm eligibility, coverage limits, and any other policy-specific requirements to minimize the chances of triggering an investigation.
3. Comply with Regulations: Familiarize yourself with jurisdictional regulations that may apply to your claims. Ensure that you are aware of any additional information or documentation that may be required to comply with these regulations and include it with the claim submission.
4. Review for Accuracy: Double-check all claim information for accuracy before submission. Ensure that all patient details, service codes, and billing information are correct to minimize the chances of triggering an investigation due to errors or discrepancies.

5. Example Cases

Here are two examples of denial code P8:

• Example 1: A healthcare provider submits a claim for a complex surgical procedure. The payer initiates an investigation to verify the medical necessity of the procedure and requests additional documentation, such as pre-authorization records and detailed medical notes, to support the claim.
• Example 2: A property insurance claim is filed for damages caused by a natural disaster. The insurer triggers an investigation to assess the extent of the damages and requests supporting evidence, such as photographs, repair estimates, and any relevant policy documentation, to evaluate the claim.

Source: Claim Adjustment Reason Codes