CO 226 Denial Code | Everything You Need To Know

Do you want to know how to overturn CO 226 denials? This blog will dive into the reasons why insurance companies deny claims with this code. We also explore effective strategies that you can implement to get your reimbursement for those claims.

CO 226 is a denial code used by insurance companies to deny reimbursement claims. The full form of CO is contractual obligations. These obligations comprise the legally binding responsibilities set between patients, insurance companies, and healthcare providers.

Also, you can contact Health Quest and multiply your revenue with the best denial management service.

What is CO 226 Denial Code?

CO 226 code indicates that the information requested from the healthcare provider was not provided at all. The information may also not have been provided in a timely manner. It can also be either insufficient or incomplete.

Therefore, the CO 226 code is a signal to ask for additional details by the insurance company. Complete and accurate details are needed for them to process reimbursement claims.

A remark code provides a more specific explanation for the CO 226 denial code. There has to be at least one remark code with the claims denied with CO 226. Remark codes clarify the exact reason for those denials.

The remark codes can be NCPDP Reject Reason Codes. They are standardized codes that are used in the pharmacy industry. The remark codes can also be Remittance Advice Remark Codes. They are used by insurance payers to provide additional details about a claim.

These remark codes offer specific details about what information is missing or incorrect. This enables healthcare providers to take appropriate action for every denied claim. They can correct it as required and resubmit it for payment.

Common Reasons for the CO 226 Denial Code

Addressing the underlying reasons for this denial requires a detailed understanding of them. Here is an explanation for each of the reasons that can cause CO 226 denials:

• Missing or Incorrect Information

Errors in patient details such as name, date of birth, or insurance ID can lead to claim rejections. Ensuring accuracy in collecting and entering patient demographics is crucial. Similar to patient information, there can be some incorrect provider details as well. They usually comprise the National Provider Identifier (NPI) or address and can cause denials.

Double-checking these details before submission is essential. Inaccuracies or omissions in diagnostic or procedural coding can lead to denials. These codes justify the necessity of the treatment provided. Lack of supporting documents impedes the insurer’s ability to verify the claim’s validity.

As a result, it can also cause the insurer to deny those claims. Supporting documents can include medical records, referral letters, and pre-authorization forms. Proper documentation should always accompany the claim forms.

• Claim Submission Errors

Sending a claim to the wrong address or using incorrect payer information can result in a denial. Always verify the payer addresses in advance. Update your billing systems with the most current payer information as well. Submitting the same claim multiple times can be flagged as a duplicate.

This is another reason for insurance companies to deny reimbursement claims. Ensuring that follow-ups on initial claims are conducted properly can prevent this. Using an outdated or wrong form/format can also lead to immediate denial.

This is why, following the latest format as specified by the payer is crucial. Errors in the dates on which services were provided can lead to processing errors. Accuracy in recording and reporting service dates is key.

• Authorization and Pre-authorization Issues

Certain treatments require prior approval from the insurance provider. Failure to obtain those approvals or the usage of expired authorizations can cause claim denials. Incorrect details in the pre-authorization can also lead to denials. This happens even when the pre-authorizations are timely obtained. In such cases, the details provided may not match the medical procedures conducted.

• Incorrect Place of Service and Modifiers

Errors in coding where the service was provided can affect how a claim is processed. The place of service usually comprises office, home, and inpatient locations. Modifiers are also critical as they provide additional context to procedures. Missing or invalid modifiers can also lead to an incorrect processing of claims.

• Incorrectly Billed Bundled Services and Communication Breakdown

Some services are to be billed together under a single code. Separating these services can lead to denials due to unbundling violations. Failures in communicating with insurers can also cause denials. You may not be receiving updates from the relevant insurance company. This can be due to incorrect contact information. It is also possible that you are unable to respond to communications from the payer.

• No Details Provided and Inadequate Response

Some hospitals do not provide all the required information even if an insurer has requested them. This can cause those insurance companies to deny your reimbursement claims. You may also have been sending incomplete responses to their inquiries. These inquiries are usually about specific claims, which is why they are turned down.

It is also possible that a healthcare provider responds to a request for additional information. This information can be either insufficient or may not meet the payer’s requirements. As a result, those claims are likely to be denied by that insurance company.

• Delay in Information and Guidelines Not Followed

Timelines are crucial and delayed responses to information requests are not acceptable. There are often delays from hospitals in providing the details requested by insurers. These delays can lead to long processing periods and denials.

Each insurance company can have its own set of rules and guidelines. Healthcare providers have to follow all payer-specific guidelines for claims submission. They must be strictly followed. This way, you can save your claims from getting denied.

How to Avoid CO 226 Denial Code?

Implementing strategies to prevent CO 226 claim denials is crucial in medical billing. processes. We have elaborated on the main strategies that you can implement to avoid the CO 226 denial code:

• Timely and Complete Information Submission

At the point of service, you must collect all necessary information from your patients. These details can include their demographics, insurance details, and medical history. This practice reduces the likelihood of errors and omissions. Such errors and omissions can lead to denials.

Ensure all relevant medical records are detailed and accurately documented. These details can include treatment plans, progress notes, and discharge summaries. By doing this, you can substantiate the medical necessity of your billed services.

Quickly and thoroughly respond to any additional information requests from payers. Delays or incomplete responses can lead to denials. This is why, it is important to handle these requests on a priority basis.

• Review and Double-Check Documentation

Implement a strict auditing process before claim submission. This review should verify the accuracy of all patient information. You can also check the appropriateness of diagnostic and procedural codes. In addition, you can determine whether your documentation matches with the billed services.

Ensure that all coding is accurate and up-to-date. You should assign medical codes according to the latest standards and payer-specific guidelines. Check that the documentation clearly supports the services billed. It should contain appropriate details that align with the coding and billing requirements.

• Improve Communication with Insurance Companies

You should maintain effective communication between your billing department and insurance companies. This way, all the relevant information can be accurately transmitted and understood. Keep your billing department informed about any changes in patient status as well. They should also be aware of the treatment plans and insurance details.

Any changes in them can significantly affect billing and claims submission. Encourage a collaborative approach to resolve issues related to billing and documentation. Your approach can reduce the likelihood of errors that could lead to denials.

• Documentation Management Systems

Utilize Electronic Health Record systems to enhance the accuracy and accessibility of patient records. Those systems can ensure that all information is up-to-date and easily retrievable. Maintain all documentation in a centralized repository system.

Such systems make documents simpler to manage and access. This comes in handy when you have to either bill or audit them. Follow all legal and regulatory requirements for document retention. This practice ensures that all necessary information is available for audits and appeals.

• Conduct Regular Training and Education

Regularly train your billing staff on the latest coding practices and billing procedures. It will help them stay informed of current standards and requirements. Emphasize the importance of clear, concise, and complete documentation among your clinical staff.

This practice plays a critical role in supporting billed services. Keep them updated on any changes in healthcare regulations and payer policies as well. By doing this, you can ensure compliance and reduce the risk of denials.

• Monitor and Track Claim Submissions

Implement a system to systematically monitor and analyze denials. Such systems effectively identify common causes and trends. You can use this information to address those causes and trends. This will help you improve your billing process with less denials.

Use key performance indicators (KPIs) related to claim submissions and denial rates. You can use them to measure the effectiveness of current practices. Apart from this, they can also be used to identify areas for improvement.

Generate regular reports on the status of claims and patterns in denials. This will help you make informed decisions. These decisions can be about refining your billing processes and preventing any relevant errors.

How Does Health Quest Billing Help Prevent Claim Denials?

Health Quest Billing can prevent claim denials by implementing several advanced strategies. We implement integrated software solutions that connect directly with payers. Our billers can ensure real-time eligibility verification and pre-authorization. This significantly reduces the chances of denials caused due to coverage issues.

We can also provide healthcare organizations with detailed reports. These reports are made after comprehensively analyzing reimbursement claims. This enables our billers to identify denial patterns and common errors. They can also implement targeted corrective actions to improve overall billing accuracy.

Health Quest Billing also offers a dedicated billing team to each hospital client. Their teams are always focused on managing and appealing denials. They specifically work to understand the specific reasons behind each denial. This is how they are able to address them and implement measures to prevent similar issues.

We also maintain strong relationships with insurance companies. Our relationships help us gain insights into specific payer requirements and expectations. We use them to customize our billing practices accordingly and preempt potential denials.

The Bottom Line

CO 226 denials are caused due to issues with the information provided in reimbursement claims. Insurance companies deny those claims primarily due to invalid details, claim submission errors, and other reasons.

You can avoid such denials by reviewing your documents, improving communication, and other strategies. Contact Health Quest Billing to ensure that your claims are safe from the mistakes that cause such denials.