Guest JWB19 Posted May 26, 2011 Posted May 26, 2011 Does anyone know where to locate a comprehensive list of "denial codes" that will need to be included in an adverse benefit determination (for non-grandfathered plans)? Thanks.
GBurns Posted May 26, 2011 Posted May 26, 2011 What are "denial codes" ? What is an "adverse benefit determination"? How are they used and by whom? I have never heard of these before and would welcome further info. Thanks. George D. Burns Cost Reduction Strategies Burns and Associates, Inc www.costreductionstrategies.com(under construction) www.employeebenefitsstrategies.com(under construction)
leevena Posted May 26, 2011 Posted May 26, 2011 Does anyone know where to locate a comprehensive list of "denial codes" that will need to be included in an adverse benefit determination (for non-grandfathered plans)? Thanks. Good question. I have not found one, but I do have one for Medicaid. My guess (which you should not go by) is that DOL will utililze the same list...but then again who knows.
leevena Posted May 26, 2011 Posted May 26, 2011 What are "denial codes" ?What is an "adverse benefit determination"? How are they used and by whom? I have never heard of these before and would welcome further info. Thanks. Adverse benefit determination is required by health care reform. It requires a notification of why a benefit for a treatment/service is being denied. Part of the reporting requires a reason, and the denial codes provide that reason.
Guest JWB19 Posted May 26, 2011 Posted May 26, 2011 An adverse benefit determination is defined in 29 CFR 2560.503-1 (the so-called ERISA Claim Regulation). The Claim Regulation has been around for some time now. It provides the timing requirements as well as the form and content requirements of benefit denials. Special rules apply to group health plans within the Claim Regulation itself, and health care reform added more. One of those new requirements is that the claim denial letters have the "denial code" and its corresponding meaning. The best list I've found is here http://www.wpc-edi.com/content/view/698/1, which provides the Claim Adjustment Reason Codes (CARC). Those are referenced in the preamble to the regulations issued last July.
GBurns Posted May 27, 2011 Posted May 27, 2011 Why change the name from the well established "Claim adjustment reason codes " to "denial codes"? George D. Burns Cost Reduction Strategies Burns and Associates, Inc www.costreductionstrategies.com(under construction) www.employeebenefitsstrategies.com(under construction)
Ron Snyder Posted May 27, 2011 Posted May 27, 2011 Why change the name from "PWBA" to "EBSA"? It's a new administration.
GBurns Posted May 28, 2011 Posted May 28, 2011 What "new administration"? The name change was proposed in 2001/2002 and was effective early 2003. George D. Burns Cost Reduction Strategies Burns and Associates, Inc www.costreductionstrategies.com(under construction) www.employeebenefitsstrategies.com(under construction)
oriecat Posted May 31, 2011 Posted May 31, 2011 2001 would have been the new (at the time) GW Bush administration.
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