835 Healthcare Policy Identification

mamador2

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Okay, please don't post a link to lists of vague medicare denial codes, I've read through the PDF's I could find on google already and they weren't very helpful to me. I'm looking for a simple plain english definition of what the heck 835 Healthcare Policy Identification Segment denial code actually means, and what loop 2110 REF is and where to find these things I'm supposed to be able to refer to. I've attached an example of a common 835 denial code description. Any help is appreciated, thanks

Adjustment Group Codes
PI : Payor Initiated Reductions

Adjustment Reason Codes
97 : The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
 

CodingKing

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Its a section of the 835 EDI file where the payer can communicate additional information about the denial. Its not always present so that could be why you cant find it. I'm not sure what software you use and I'm not very familiar with many so if you don't know where this information populates you may wabnt to check with your EDI vendor

For example this is what Blue Cross transmits

This segment may be sent only for BlueCard remittances if the data has been returned from the Blue home plan. If present, the 1000A PER Medical Policy URL segment is also sent.
 

lmmom64

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Depends on the reason. We have been getting "diagnosis is inconsistent with the procedure"denials a lot-- I work for an ambulance company. So we are submitting retro auth appeals because insurance said they denied because the trips didn't have prior authorization AND an ICD-10 code consistent with transport.
 
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