CO 185 Denial Code - Provider Eligibility Fix
Code 185 indicates that the rendering provider is not eligible to perform the service billed. This means that the payer has determined the provider does not meet the necessary criteria to render the specific service on the claim. The specific reason might be detailed in the 835 Healthcare Policy Identification Segment if available.
Who Pays: Group Code Liability
Typically, CO applies to code 185, meaning the charge should be written off and not billed to the patient. However, if the payer policy or contract allows, PR might apply, making it billable to the patient. Verify with the payer.
Why Claims Get Code 185
- Provider is not credentialed with the payer for the specific service.
- Provider's license does not cover the procedure billed.
- Service was rendered by a provider type not recognized for the procedure.
- Provider's specialty is not eligible for the service billed.
- Payer has specific credentialing requirements not met by the provider.
How to Fix & Resubmit
- Verify the provider's credentials and eligibility for the service billed.
- Check the payer's specific requirements or policies related to provider eligibility for the service.
- Correct the provider information on the claim if it was submitted incorrectly.
- Consider rebilling with a different provider if they are eligible for the service.
- Contact the payer for clarification if the denial reason is unclear.
Corrected Claim or Appeal?
For code 185, a corrected claim is appropriate if the error was due to incorrect provider information. If the provider is indeed ineligible, appealing may not be successful unless the payer's policy was misapplied.
Preventing Future 185 Denials
- Ensure providers are credentialed and eligible for all services they perform.
- Maintain updated records of provider licensing and credentialing.
- Verify payer-specific requirements before submitting claims.
- Regularly review provider eligibility with payers to avoid denials.