288Denial Code (CARC)Active
Denial Code PR 288 - Referral Absent: Fix & Appeal Steps
Code 288 means the claim was denied because a required referral was not on file with the payer. This indicates that the payer needed a referral from a primary care physician or another referring provider to process the claim, and it was missing.
Who Pays: Group Code Liability
With code 288, the liability often falls under PR, meaning the patient might be responsible for the payment since the referral requirement was not met. However, if the provider failed to secure the referral, it could be a CO adjustment where the patient isn't billed. Check specific payer policy for guidance.
Why Claims Get Code 288
- The provider office did not request a referral from the primary care physician.
- The referral was not sent to the payer before the claim was submitted.
- The referral was sent but not processed by the payer due to an administrative error.
- The referral was issued but expired before the date of service.
- The referral did not cover the specific services billed.
How to Fix & Resubmit
- Verify whether a referral was actually required for the services billed.
- Check patient records to see if a referral was obtained and submitted to the payer.
- If a referral exists, contact the payer to determine if it was received and linked to the claim.
- If no referral was obtained, request one from the referring provider and resubmit the claim.
- If a referral was submitted but not processed, provide documentation and request a claim reprocessing.
Corrected Claim or Appeal?
Submit a corrected claim if a missing or incorrect referral was the issue. If a valid referral was submitted but not linked, an appeal with supporting documentation is warranted.
Preventing Future 288 Denials
- Ensure referral requirements are verified during patient scheduling and registration.
- Implement a system to track referral requests and confirmations before claims submission.
- Train staff to check referral validity and expiration dates before patient appointments.
- Regularly audit claims to ensure referral compliance with payer requirements.