CARC 273 Denial Code - Coverage Guidelines Exceeded
Code 273 indicates that the claim was denied because the services provided exceeded the coverage or program guidelines set by the payer. Essentially, this means that the payer has determined that the service limits or frequency restrictions outlined in the patient's plan have been surpassed.
Who Pays: Group Code Liability
With code 273, the group code can vary. If CO is assigned, it means the provider must write off the amount and cannot bill the patient. If PR is assigned, the patient may be responsible for the amount, depending on their plan details.
Why Claims Get Code 273
- The patient received services more frequently than allowed by their insurance plan.
- The total number of services for the year exceeded the plan's maximum coverage limit.
- The provider did not verify the patient's benefit limits prior to rendering services.
- The claim included a service or procedure not covered due to plan restrictions.
- A prior authorization was required but not obtained for the service in question.
How to Fix & Resubmit
- Verify the patient's plan details to confirm the specific coverage limits and guidelines.
- Check if the service exceeded frequency or quantity limits according to the plan.
- If applicable, contact the payer to discuss the possibility of an exception or appeal based on medical necessity.
- Submit a corrected claim if an error was made in reporting the service frequency or quantity.
- If the denial is valid and CO applies, adjust the account accordingly. If PR applies, bill the patient if their plan allows.
Corrected Claim or Appeal?
Submit a corrected claim if the denial was due to a reporting error. Appeal if the denial seems unjustified and you have supporting documentation for medical necessity. If the denial aligns with plan terms, it may be a valid adjustment with no further action needed.
Preventing Future 273 Denials
- Verify coverage limits and guidelines before providing services to ensure compliance.
- Implement checks to track service frequencies against plan limits.
- Ensure prior authorizations are obtained and documented when required by the payer.
- Educate staff on common plan restrictions and guidelines to prevent future denials.