213Denial Code (CARC)Active
CO 213 Denial Code - Fix Self-Referral Issues
Code 213 indicates that the claim was denied due to non-compliance with physician self-referral prohibition legislation or a specific payer policy. This means the service billed may involve a conflict of interest, such as a financial relationship not allowed under applicable laws or payer rules.
Who Pays: Group Code Liability
For code 213, the liability typically falls under CO, meaning the provider must write off the amount and cannot bill the patient. Verify with the payer, as specifics might vary by contract or policy.
Why Claims Get Code 213
- The provider has a financial interest in the entity providing the referred service.
- The service was referred to an entity owned by the physician or their family, violating self-referral laws.
- The claim was flagged by the payer for a potential conflict of interest not disclosed or allowed.
- The billing office failed to document an exception to the self-referral prohibition, if applicable.
- The claim did not include necessary disclosures or documentation to prove compliance with payer policy.
How to Fix & Resubmit
- Review the claim for any self-referral relationships that may violate legislation or payer policy.
- Check if there are applicable exceptions to the self-referral prohibitions and gather documentation.
- Contact the payer to clarify the specific reason for the denial and any possible resolution options.
- If applicable, correct the claim with proper documentation or select a compliant service provider.
- Resubmit the claim with the necessary corrections or documentation as advised by the payer.
Corrected Claim or Appeal?
For code 213, if a valid exception exists or documentation was missing, submit a corrected claim with the proper information. If the denial is based on a strict policy without exceptions, an appeal is unlikely to succeed.
Preventing Future 213 Denials
- Ensure full understanding of self-referral laws and payer-specific policies before billing.
- Implement a checklist to verify compliance with self-referral prohibitions for each claim.
- Regularly train staff on recognizing and documenting exceptions to self-referral rules.
- Maintain thorough documentation of any financial relationships and relevant exceptions.