One main challenge that healthcare providers face during financial management is claim denials. Frequent claim denials occur when providers are unable to identify the reasons behind them and prevent the billing errors that trigger them. Even minor coding mistakes and negligence in data entry can lead to claim denials, which significantly impact the practice’s revenue cycle.
Denial code 119 is a result of such negligence on the provider’s and biller’s end. It occurs when healthcare providers render the service and bill for it without checking the insurance plan’s benefit limitations.
This blog will cover the reasons behind the denial code 119, along with practical solutions and recommended best practices to prevent its recurrence.
Denial Code 119 – Description
Denial code 119 indicates that the patient has exceeded the maximum benefit limit permitted for a specific service or procedure. The denial code 119 is triggered when the patient’s medical insurance plan has capped a service (for example, limited it to 6 times per year), but the healthcare provider exceeds that threshold. Hence, the insurance payer will reject further claims for the same service or treatment until the new time period starts and the limit is reset.
Typically, physical therapy, occupational therapy, and speech-language pathology have annual therapy thresholds. So, 119 denials will most commonly occur in that context. Note that in calendar year 2025, the Medicare therapy threshold for occupational therapy services is $2,410. So, if you provide any more occupational therapy services beyond this amount without appending modifier KX, your claim will be denied with denial code 119.
Common Causes of Denial Code 119
Are there any evident causes that can trigger denial code 119? Yes! These are some significant errors that lead to CO-119 denials.
Exceeding the Benefit Limit
Did you know that insurance payers usually limit some treatments and services. They limit the coverage to a few times in a specific period. If you exceed that limit, the insurance payer will automatically reject your claim with a denial code 119. For example, Medicare limits trigger point injection sessions to 3 times per year.
Prior Authorization
Some services require prior approval, particularly if you exceed the benefits limit. If you do not obtain the payer’s prior authorization for the service that is beyond the threshold, your claim may be denied with denial code 119.
Errors in Claims
Entering incorrect information is one of the most common mistakes that providers make when billing. Inaccurate and incomplete information in claims and supporting documentation leads to confusion, misinterpretation, and eventually claim denials. What if the insurance payer misinterprets or miscalculates the number of times the service was rendered? He will reject the request with a denial code 119.
Policy Changes
Sometimes denials also occur when the billing party is unaware of changes in the payer policy or the discontinuation of a specific plan or certain benefits. Imagine that the insurance payer revises plan benefits and sets a limit on certain services. Unaware of the changes, you bill for more than the specified limit. In this case, denial code 119 will be triggered.
Denial Code 119 – Prevention Techniques
There are some prerequisites and tricks that you may follow to prevent the denial code 119.
Check Insurance Benefits
Before rendering services and submitting claims, confirm the patient’s insurance coverage, including plan benefits, limitations, and exclusions. This will prevent you from exceeding the set limit, and you will not receive a rejection with the denial code 119.
Obtain Prior Authorization
As we have discussed, not obtaining prior approval from the payer may be the reason for this denial. Hence, you must get the payer’s approval for services that are likely to go over benefit restrictions due to medical necessity. This prevents denials later on by guaranteeing that the insurance payer authorized the treatment before its delivery.
Apply KX Modifier
The KX modifier indicates that some medically necessary services have surpassed the maximum limit. For Medicare patients, you can bill over the standard therapy threshold by using this modifier. KX highlights that the services beyond the threshold were medically necessary. Therefore, the payer should examine the claim instead of denying it straight away.
Reduce Billing Errors
Even a minor coding or data entry mistake can trigger a claim denial. Therefore, you must double-check all the entered information (including codes, service dates, patient information, and modifiers) and supporting documentation before filing the claim. You can avoid wasting time and money on denied claims by making this simple effort.
Denial Code 119 – Resolution Steps
We have discussed the causes and prevention strategies for the denial code 119. But what can you do if you see this denial on your Electronic Remittance Advice (ERA)? How do you resolve it? Below are some steps that you can take to resolve this denial and resubmit the corrected claim.
Find Out the Reason
The first step in resolving denial code 119 is to identify the root cause. There could be multiple reasons, such as incorrect information, missing prior authorization, or not applying the modifier. Hence, review your submitted claim and supporting documents to detect coding or data entry errors.
Confirm Insurance Limits
Examine the patient’s insurance policy/plan to ascertain the benefits limits and ensure that you have not exceeded the maximum.
Address the Issues
Once you have determined the actual reason behind denial code 119, it is time to let your patient know about these concerns. Inform the patient that they have already received the maximum benefits allowed under their plan and are not eligible for any more covered services. Discuss payment options such as self-pay or community-sponsored healthcare.
File an Appeal
Lastly, you can file an appeal with the insurance payer if you think that the denial occurred for unfair reasons. You can further support your claim with essential paperwork such as medical records and documents that prove medical necessity. All of these steps for appeal should adhere to the insurance payer’s specific appeal process.
How MediBillMD Can Help Resolve Denial Code 119?
Denial code 119 occurs when the biller exceeds the maximum benefits limit set by the insurance payer. However, we have discussed in detail the reasons for this denial and tips to prevent this denial code. Furthermore, we have also provided a step-by-step guide to resolve the Denial Code 119.
However, if you still find it challenging to resolve this denial, you can outsource denial management to MediBillMD and enjoy complete payments for your services.
