Medicaid Denial Codes vs Medicaid Explanation Codes

Are you trying to determine the root causes of your Medicaid Denials by analyzing their Denial Codes only to find the majority of Denial Codes are ANSI Code 16?

As you probably know Denial Code 16 doesn’t tell you anything.

Here is the technical description for Code 16: Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.

The only way to get meaningful data to determine the root causes of Medicaid Denials is to report on the Medicaid Explanation Codes or Medicaid EOB Codes provided on the “hard-copy” reports.

The Medicaid Explanation Codes are much more detailed and provide the data needed to allow a facility to take corrective steps required to reduce their Medicaid Denials.

There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16.

Here are just a few of them:

EOB CODE	Description
3101	The taxonomy code for the attending provider is missing or invalid
191	Medicaid id number does not match patient name
2434	Per 42 CFR 455.410, all medical professionals who provide services to NC Medicaid and/or NC Health Choice recipients must enroll in those programs
9061	Edit limit exceeded
41	Federal sterilization consent form required
41	Federal sterilization consent form required
132	Rebill with patient liability amount and/or correct admission date
94	Resubmit claim indicating private insurance payment or applicable occurrence code. If documented insurance denial required submit with claim on provider inquiry form
2435	Per 42 CFR 455.410, all medical professionals who provide services to NC Medicaid and/or NC Health Choice recipients must enroll in those programs
2671	ICD version invalid for date of service
319	Point of origin code submitted is missing or is not in accordance with medicaid policy. Rebill with correct source of admission code. Refer to UB manual
143	Medicaid id number not on state eligibility file
3102	The taxonomy code for the billing provider is missing or invalid

BridgestoneHRS provides full and robust reporting on all Medicaid Explanation Codes.

We can show you the exact root causes of your Medicaid Denials. Additionally, with our Trend Reports we you will have a clear understanding of your facilities progress in minimizing your Denied Claims.

Free Medicaid Explanation Denial Code Report Package Offer

We will also prepare you an analysis of 12 months of your Medicaid Explanation Code Data at no cost. Our expert staff will review and present the data to you via our on-line Denials Workshop.