B1 Denial Code - Non-covered Visits, Fix & Appeal Steps
Code B1 indicates that the payer has identified certain visits as non-covered under the patient's plan. This means that the services rendered during these visits are not eligible for reimbursement, based on the coverage terms.
Who Pays: Group Code Liability
For code B1, the group code used is typically CO, meaning the provider must write off the charges as a contractual obligation and cannot bill the patient for these non-covered visits. However, if the provider believes the service should be covered, checking the payer's specific policy is recommended.
Why Claims Get Code B1
- The patient's insurance plan does not cover the specific type of visit performed.
- The service was provided outside of a covered network or facility.
- The patient's policy has specific exclusions for the visit type.
- The visit exceeded the benefit limits outlined in the patient's plan.
- The coding on the claim did not match the services covered under the patient's plan.
How to Fix & Resubmit
- Verify the patient's insurance plan details to confirm coverage exclusions.
- Check if the service was performed at an in-network facility and within policy guidelines.
- Review the coding on the claim to ensure it reflects covered services.
- Contact the payer for clarification if the visit should be covered based on the policy.
- Submit a corrected claim if a coding error is identified, or appeal if coverage was denied inappropriately.
Corrected Claim or Appeal?
Submit a corrected claim if the issue was due to a coding error. If the service should be covered according to the patient's policy, a formal appeal may be necessary. If the denial is valid according to plan terms, neither action is applicable.
Preventing Future B1 Denials
- Verify coverage details before scheduling non-emergency visits.
- Ensure coding accurately reflects covered services at the time of claim submission.
- Confirm network status of facilities before rendering services.
- Educate billing staff on common exclusions in prevalent insurance plans.