279Denial Code (CARC)Active
Denial Code PR 279 - Out-of-Network Provider Fixes
Code 279 indicates that the services were not provided by a preferred network provider. This means the patient received care from a provider outside of their designated network, leading to reduced or denied reimbursement.
Who Pays: Group Code Liability
For code 279, the liability typically falls under PR, making the patient responsible for the costs not covered by their insurance. The patient can be billed for these out-of-network charges.
Why Claims Get Code 279
- Patient received services from an out-of-network provider.
- Provider is contracted but not within the member's specific narrow network.
- Patient's insurance plan has strict network limitations.
- Services were rendered at a facility not covered by the patient's plan.
- Incorrect provider network information on file.
How to Fix & Resubmit
- Verify the provider's network status with the patient's insurance plan.
- Check if the patient was informed of the network restrictions prior to receiving services.
- Confirm whether there is any possibility of a network exception or authorization for this service.
- If the provider is indeed out-of-network, bill the patient for the remaining balance.
- If an error occurred in network designation, resubmit the claim with corrected information.
Corrected Claim or Appeal?
Submit a corrected claim if the provider was mistakenly identified as out-of-network. If the provider is truly out-of-network, billing the patient may be the appropriate step; appeals are unlikely to succeed unless an exception applies.
Preventing Future 279 Denials
- Verify the patient's network restrictions before scheduling services.
- Maintain updated records of provider network statuses for insurance plans.
- Educate patients on the importance of using in-network providers.
- Implement a pre-service verification process for network eligibility.