78Denial Code (CARC)Active
CARC 78 Denial Code - Resolve Non-Covered Days
CARC 78 indicates that the payer has adjusted the claim due to non-covered days or room charges. This means that specific days of the patient's stay or certain room charges are not covered under the patient's policy, and the payer will not reimburse for these charges.
Who Pays: Group Code Liability
For CARC 78, if the group code is CO, the provider must write off the charge, and the patient cannot be billed. If the group code is PR, the patient is responsible for these charges and can be billed accordingly.
Why Claims Get Code 78
- The patient's insurance plan does not cover certain inpatient days.
- The room type billed exceeds the patient's plan coverage.
- The hospital stay extended beyond the authorized or covered period.
- Coding errors related to room charges or stay duration.
- Lack of prior authorization for extended stay.
How to Fix & Resubmit
- Verify the patient's insurance policy to confirm coverage details for room charges and stay duration.
- Check if the stay exceeded authorized days or if a specific room type was not covered.
- Contact the payer to clarify the reason for non-coverage if unclear from the remittance advice.
- If applicable, correct any coding errors related to room type or stay duration and resubmit the claim.
- If the non-coverage is due to lack of prior authorization, request a retroactive authorization if possible.
Corrected Claim or Appeal?
Submit a corrected claim if a coding error or incorrect room charge was billed. If non-coverage is due to policy terms, an appeal may not be successful unless you have grounds, such as obtaining a retroactive authorization.
Preventing Future 78 Denials
- Ensure verification of coverage details for room charges and stay duration before admission.
- Obtain prior authorization for the entire expected duration of the stay.
- Train staff on accurate coding for room types and duration of stay.
- Regularly review payer policies for updates on covered services and room charges.