292Denial Code (CARC)Active
CARC 292 Denial Code: Benefits Not Available Fix Steps
Code 292 indicates that although the medical plan received the claim, the services are not covered under this plan's benefits. Instead, the claim has been sent to the patient's pharmacy plan to see if they will cover it.
Who Pays: Group Code Liability
With code 292, the group code is typically CO, meaning the provider must write off the amount and cannot bill the patient. However, if the pharmacy plan denies coverage, check if the patient can be billed under PR.
Why Claims Get Code 292
- The service was billed under the medical plan instead of the pharmacy plan.
- The patient's benefits do not include the billed service under the medical plan.
- Coordination of Benefits (COB) was not properly established.
- The patient's plan information was outdated or incorrect.
- The claim was submitted with an incorrect plan type.
How to Fix & Resubmit
- Verify the patient's plan details to ensure accurate billing to the correct plan.
- Check the COB setup to confirm the pharmacy plan is correctly identified as secondary.
- Contact the pharmacy plan to confirm receipt of the forwarded claim and inquire about their processing timeline.
- If the pharmacy plan denies the claim, determine if the patient should be billed or if a different resolution is needed.
- Update the patient's records with current plan information to avoid future errors.
Corrected Claim or Appeal?
For code 292, appeals aren't typically necessary unless the pharmacy plan denies the claim and coverage should apply. Corrected claims aren't needed unless initial plan information was wrong.
Preventing Future 292 Denials
- Ensure initial patient registration captures complete and accurate plan details.
- Train staff to verify if services should be billed to medical or pharmacy plans.
- Regularly update patient insurance information to maintain accuracy.
- Establish clear COB processes to avoid misrouting claims.