CO 198 Denial Code: Fix Precertification Issues
Code 198 indicates that the service in question exceeded the bounds of the precertification, notification, authorization, or pre-treatment requirements. This means the payer determined that the treatment provided went beyond what was initially approved, either in scope or duration.
Who Pays: Group Code Liability
For code 198, the group code is typically CO, meaning the provider must write off the amount and cannot bill the patient. However, if the service was elective or non-emergent, PR may apply, making the patient potentially responsible for the charges.
Why Claims Get Code 198
- The service was not fully covered by the initial authorization.
- The authorization expired before the service was provided.
- The procedure exceeded the number of visits or units authorized.
- The wrong authorization number was used on the claim.
- The authorization was not obtained or updated following a change in treatment plan.
How to Fix & Resubmit
- Review the authorization details to confirm the approved services and dates.
- Check if the service provided exceeded the authorized amount or scope.
- Contact the payer to understand the discrepancy and determine if a retroactive authorization is possible.
- If an error occurred in the authorization reference or scope, submit a corrected claim with the right details.
- If required, request an appeal or retroactive authorization from the payer, providing necessary documentation.
Corrected Claim or Appeal?
Submit a corrected claim if the error was due to incorrect authorization details. If the service genuinely exceeded the authorization, an appeal may be needed to seek retroactive approval, especially if the service was medically necessary.
Preventing Future 198 Denials
- Ensure all services match the authorization in terms of type and quantity before billing.
- Verify authorization details against the claim to prevent mismatches.
- Establish a protocol for checking authorization expirations and extensions.
- Educate staff on the importance of obtaining updated authorizations when treatment plans change.