CARC 179 Denial Code - Resolve Waiting Period Issues
CARC 179 indicates that the patient has not met the required waiting period for the service billed. This waiting period is typically associated with specific coverage or benefit requirements outlined in the patient's insurance plan. The 835 may include additional policy identification details in the 2110 REF segment to clarify the waiting period specifics.
Who Pays: Group Code Liability
With CARC 179, the group code is usually PR, meaning the patient is responsible for the cost. However, if the waiting period is a standard part of the plan and not met due to a billing error, it might be a CO adjustment, requiring a write-off without billing the patient.
Why Claims Get Code 179
- Patient's insurance plan includes a waiting period for the specific service or treatment.
- Billing was submitted before the waiting period was completed.
- Insurance policy changes not updated in the system, leading to premature billing.
- Miscommunication about the effective date of coverage or benefits.
How to Fix & Resubmit
- Verify the patient's insurance plan details to confirm the waiting period requirements.
- Check the 835's 2110 REF segment for specific policy information related to the denial.
- If the waiting period was incorrectly identified, update the system with the correct dates and resubmit the claim after the waiting period is met.
- Contact the payer for clarification if the waiting period details are unclear or if you suspect an error.
- If applicable, inform the patient about their responsibility and discuss any payment options if the waiting period was not met.
Corrected Claim or Appeal?
Submit a corrected claim if the initial submission was premature. If the waiting period was met but a denial was received, contact the payer for clarification or appeal if necessary. Legitimate waiting period denials generally should not be appealed unless an error is evident.
Preventing Future 179 Denials
- Ensure accurate entry of insurance plan details, including waiting periods, in the billing system.
- Implement a verification step to confirm waiting period completion before claim submission.
- Stay updated on insurance policy changes that could affect waiting period requirements.
- Educate staff on common waiting period requirements for major payers to prevent future denials.