Jump to content

Internal Review


Guest JWB19

Recommended Posts

Guest JWB19

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.

Link to comment
Share on other sites

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)

Link to comment
Share on other sites

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.

Link to comment
Share on other sites

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.

Link to comment
Share on other sites

Guest JWB19

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.

Link to comment
Share on other sites

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)

Link to comment
Share on other sites

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)

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...