Denial code 272, which indicates that “coverage/program guidelines were not met,” is a frequent issue faced by healthcare providers. This type of denial often results in lost revenue and administrative headaches. However, understanding its common causes and implementing targeted strategies can help practice managers, healthcare providers, and practice owners reduce these denials and streamline their revenue cycle.
Why Does Denial Code 272 Occur?
- Unmet Coverage Requirements
Certain services or procedures may not be covered under the patient’s insurance plan, leading to denial if these coverage requirements aren’t met. - Exceeded Plan/Program Guidelines
If a claim exceeds the coverage limits or frequency restrictions of the insurance plan, a denial may occur. - Non-Compliance with Case Management
Some insurance plans require case management; non-adherence to these guidelines can trigger a denial. - Incorrect Patient Information
Errors in insurance ID numbers or demographic details can lead to rejections and unnecessary delays. - Coordination of Benefits (COB) Errors
When multiple insurance plans are involved, incorrect coordination of benefits may result in denials. - Insufficient Medical Records
Medical records that fail to demonstrate medical necessity or justify services can lead to a lack of coverage. - Lack of Prior Authorization
Some services need pre-authorization from the insurance company, and failure to obtain it will likely result in a denial. - Technical Errors
Mistakes in claim submission or data entry can contribute to denial issues.
Strategies to Prevent and Resolve Code 272 Denials
- Review ERA/EOB Thoroughly
Examining Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) statements helps identify the exact reasons for denial, aiding in quick resolution. - Eligibility and Coverage Verification
Verify each patient’s eligibility and coverage before services are provided. This simple step can help prevent denials from unmet coverage requirements. - Prior Authorization
For procedures that need it, ensure prior authorization is obtained to avoid denials. - Accurate Claim Information
Double-check all patient details and claim information to prevent denials due to incorrect entries. - Effective Coordination of Benefits
When dealing with multiple insurance plans, follow the proper COB procedures to avoid confusion and rejection. - Maintain Comprehensive Medical Records
Keep thorough records that justify the medical necessity of each service. This helps avoid denials related to insufficient documentation. - Adhere to Payer Guidelines
Stay updated on payer-specific guidelines and ensure compliance for smooth claim processing. - Optimize Electronic Health Record (EHR) Use
Use EHR tools to improve accuracy, minimize technical errors, and streamline claim submissions. - Track Denials and Appeals
Monitor denied claims, file timely appeals, and keep a record of appeal outcomes to address recurring issues.
Partnering with Claims Med
Proactively addressing the reasons for code 272 denials can help improve your practice’s revenue cycle management and patient care. However, it can be time-consuming and complex to navigate these challenges alone. Consider partnering with Claims Med for comprehensive revenue cycle management solutions. Our expertise in billing, coding, and claims appeals can help you minimize denials, maximize reimbursements, and optimize your practice’s financial health.
Contact Claims Med today to learn how we can support your practice in tackling denial code 272 and other billing challenges.