Still thinking about your denied claim? Look at the denial code to discover the reason. Each code highlights different issues in your claims, from coverage limitations to incorrect or missing payer information. By understanding the most recurring reasons, you can avoid the patterns or mistakes in your billing process that result in claim rejections.
So, which denial code do you often receive? If it is denial code 226, then you are at the right place! Let us help you understand everything about this code, from its description and reasons to prevention and resolution.
CO 226 Denial Code – Description
Did you provide all the relevant details to the payer? If not, you might be familiar with this code. The CO 226 denial code simply indicates that the requested information was either not provided at all, not submitted on time, or was insufficient or incomplete.
In other words, this code is triggered when the provider (rendering or billing provider) responsible for patient care fails to submit the required information to the insurance company.
Keep in mind that 226 is specifically a Claim Adjustment Reason Code (CARC), a standard code issued by insurance companies to explain why they paid a service differently. However, 226 is often referred to as a Contractual Obligation (CO) denial code due to the misinterpretation of the payer-provider contract.
Another thing to remember is that insurance companies usually pair the CO 226 denial code with at least one type of Remark Code, either the NCPDP Reject Reason code or the Remittance Advice Remark Code (RARC). But what is a Remark Code?
Remark Codes Used with CO 226 Denial Code
Some payment adjustments come with additional details. Insurance companies use Remark Codes to provide that. In simple terms, Remark Codes, maintained by CMS, typically communicate the extra information about why an insurance company has reimbursed a service differently or rejected a claim. In short, they cover details that Claim Adjustment Reason Codes don’t.
As mentioned before, insurance companies usually use either a Remittance Advice Remark Code (RARC) or an NCPDP Reject Reason code with denial code 226. Since NCPDP National Council for Prescription Drug Programs (NCPDP) is a unique identifier assigned to every U.S. pharmacy, insurance companies mainly use the NCPDP Reject Reason code for pharmacy claims to specify the reason for denial.
Meanwhile, they use RARC on medical claims to convey specific reasons for denying a claim or adjusting payments. In the case of the CO 226 denial code, these Remark Codes are only used to explain the issue – missing information. Hence, insurance companies avoid using generic alerts or warning codes with this denial code.
Reasons for Receiving Denial Code CO 226
The CO 226 denial code is quite common. Many healthcare providers and practices have received it for not providing the requested details to the payers. You can only address this denial if you understand its underlying causes. Here are some of the most common reasons for receiving denial code 226:
Failure to Respond to Information Requests
Insurance companies often require additional information, such as treatment details, documentation justifying the medical necessity of a service, or updated insurance details, to process your claims. If you don’t respond to their timely request, they deny your claim with the CO 226 denial code.
Missing or Insufficient Information
Even if you have provided the requested information, you might still face denial code 226 because the payer deems the details inadequate. This may include filing claims without essential elements, like patient name, date of birth, address, or insurance ID.
Inadequate Documentation
Payers also reject claims submitted without proper documentation. This often includes missing medical records, incomplete referral details, or the absence of prior authorization for complex services and procedures.
Incorrect Information
Many providers face the CO 226 denial code due to outdated or incorrect information in medical claims. For instance, errors in the patient’s personal or insurance details, inaccurate billing information, or coding mistakes can lead to payers denying your claim with this code.
Miscommunication
It all comes down to miscommunication. Denial code 226 often occurs because of missed messages or delays in responding to insurance companies’ notifications, leading to confusion between payers and healthcare providers.
CO 226 Denial Code – Management & Resolution
The CO 226 denial code can delay payments and disrupt the cash flow you need to sustain your daily operations. Want to maintain a steady revenue stream? Follow these simple tips to manage and resolve denial code 226.
Review the Denial & Remark Code
Check the denial and the Remark Code to understand the reason for claim denial. This step will help you identify which documentation or information you have failed to submit to the payer.
Gather All the Information
Pay special attention to the detailed explanation mentioned in the Remark Code. Collect all the necessary information, including the patient’s details and documentation.
Verify Insurance Details
Double-check everything, from the patient’s insurance plan to the payer’s submission policies. Make sure your database is updated and has all the latest details, including the patient’s name, insurance company, and policy number. In simple words, check whether the insurance information in your systems aligns with the patient’s current coverage.
Provide Missing/Requested Information
After identifying the missing information or documentation, take the necessary steps to receive proper reimbursement. If the payer denied your claim due to insufficient or missing information or documents – such as medical records, prior approval, or referral – gather and submit the required details.
Resubmit the Claim
Once you have obtained the missing information, update and resubmit the claim on time. Follow the payer-specific guidelines to avoid further mistakes. Attach all the required documents, fill out all the fields in the claim form, and most importantly, submit it on time, within a payer’s specified deadline.
Follow-Up
Track your claim’s progress and frequently follow up with the payer to speed up the process.
Appeal (If Required)
If the insurance company continues to decline your claim despite all the corrective measures, file an appeal. Include a detailed explanation and attach relevant documentation to justify your claim.
How to Prevent Denial Code CO 226
Prevention is the most timely and cost-effective solution. Adopt a more proactive approach to significantly reduce your staff’s administrative burden and minimize claim denials. Follow these steps to avoid denial code 226.
Improve the Patient Intake Process
The most important preventive step is to collect complete and accurate patient information. You can only do that by improving the patient intake process. Instead of doing everything manually, use the latest EHR software to avoid mistakes. Record the patient’s name, date of birth, contact number, insurance information, and other essential details accurately.
Verify Insurance Coverage
Many services require prior approvals or referrals. To avoid the CO 226 denial code, verify every patient’s insurance coverage in advance and obtain all the essential pre-authorizations and referrals.
Maintain Proper Documentation
You should have complete proof of everything, from the patient’s medical records to pre-authorizations. Simply put, maintain proper documentation so you can respond to the payer’s information requests on time.
Remember that different insurance companies have varying requirements, so make sure your staff can read between the lines and act according to the payer-specific guidelines. Most importantly, pay special attention to your medical notes. They should be clear and legible. Moreover, these medical records should include all the details about the provided treatment.
Establish Proper Communication Channels
Communication is the key to avoiding denial code 226. Therefore, communicate clearly with both payers and patients. Keep an eye on your notifications to promptly address insurance companies’ requirements. Meanwhile, help your patients understand why they need to provide accurate information.
Provide Regular Training to Your Staff
Your billing and coding teams should be familiar with each insurance company’s rules and guidelines. Therefore, provide regular training to your staff so they can understand the type of information they need to collect and submit.
Keep them updated on changes in payer policies or requirements to avoid potential mistakes that could lead to denial code 226.
Improve Your Follow-Up Process
Review every claim thoroughly before submission and check whether they include all the required documentation. Don’t forget your claims after submission. Track their progress and status and proactively respond to additional information requests.
Bottom Line
To summarize, payers issue the CO 226 denial code when providers fail to respond to their request for additional information. Although it is a commonly used code to explain payment adjustments, it is also easily avoidable.
We have covered everything you need to know about this code, from its description and associated Remark Codes to tips for resolving and preventing it. By following our instructions, you can effectively manage and avoid CO 226 claim denials.
However, if you still struggle to prevent or resolve denial code CO 226, our tailored denial management services are available for as low as 1% of the net monthly collections. Let MediBill MD’s denial experts salvage your revenue.
